2018.

Any insight, thoughts, ideas, perspective gratefully accepted.

I'm just talking Medicare/Medicaid here.

New Manual chair through Medicare/Medicaid understanding the system, what is available, what are the options, what is a good strategy for obtaining the best chair for the individual.

Not meaning to be too long winded, but basically how do we make the system work for us ?

I really don't want to go through the new chair nightmare, but my butt pain is so bad, my doctor and PT think it would really help me.

Back in 2011 when I got my current chair, I went to the PT, the DME came to the measuring session and then I just waited and waited felt like it took 12 months and then the chair arrived just as the PT prescribed. Tilite titaninium TR etc. life seemed good.

Fast forward to now and 2018 and everyone seems to be throwing their arms in the air, "there have been so many changes we could never get you that chair for you now." Different PT same DME.

So what are other folks experiencing and what really are the options.

Has anyone managed to get a titanium chair recently? ( last 6 months)

My DME is also telling me that I can't pay for the upgrade myself, medicare/medicaid won't allow it.
Also I can't pre-pay (bill unassigned) either.

Are my options really going to be I'm stuck with what whatever Medicare/Medicaid pay for
or
Pay for the whole thing out of pocket?

From my DME :
Our hands truly are tied by ill-designed policies for patient care by Medicare/Medicaid. Medicare doesn't allow us to provide an upgraded feature (like Titanium) based on their policy. Furthermore, even if they did, Medicaid would not recognize it and per Medicaid's policy we are not able, by law, to charge you the difference. Furthermore, you pre-paying doesn't work for similar purposes:

1. If you only had Medicare, this would be a possibility and we could bill unassigned (in which Medicare would pay what they pay and you've already accepted that it may be less than you had pre-paid)

2. Because you have Medicaid, we are unable to collect any payment from you (as Medicaid does cover a wheelchair, of some type, under your benefits). Legally, we are not able to collect any difference from you between what Medicaid deems "medically necessary" and what you actually received

We share the same frustrations as you, as we see this situation on a nearly daily basis. If there was a loop-hole to any of this, we would have found it by now. Unfortunately, we have consulted professionals at all levels and have yet to find it.

I wish I could be the bearer of more positive news, but the rules are stacked against it unfortunately.

From a Tilite Representative:
The current problem with Titanium chairs for clients with Medicare is related to the reimbursement amount. Just about five years ago CMS administration told us that the titanium option for MWC building material was not included in the K0005 code and could therefore be billed separately as an upgrade. It is my understanding that other manufacturer(s), that had given up on titanium frames because they did not believe that they were fundable under the current Medicare billing guidelines, were upset about this decision and asked CMS to review the definition of the K0005 code. At the beginning of 2017 CMS reversed their decision and stated that the wheelchair frame is included in the K0005 code regardless of the building material. This means that a dealer is unable to bill Medicare or a client separately for any upgrade to the building material. CMS is preventing clients from paying extra for this option even though it would not cost CMS any money. They are simply preventing access.


This means that titanium chairs are just not profitable for dealers when providing them to Medicare clients. We are actively pressuring CMS to change this rule but the current administration is not very receptive to rational ideas and we are not getting support from other MWC manufacturers that do not want us to have a competitive advantage because we can make chairs out of titanium. One more reason to be disgusted with politics these days.