Insurance vs. Cash Purchase - Know your options!

Obtaining Mobility Equipment...

   vs.  

Using your Insurance vs. Purchasing yourself….

which option makes more sense for you?

The answer may not be what you think...

YOUR BIGGEST DECISION IS THIS…do you want to get a mobility scooter or power chair that has all the options you want (and you purchase it yourself) or do you want a very basic, no thrills option through your insurance, at little or no cost?

Dealing with insurance to receive a power chair, scooter, lift chair or other equipment is a slow and complicated process. Buying yourself is a fast option and most folks get their equipment and start enjoying the benefits immediately.

“I have more money than time, I want to get what I want now!” George S. - Customer in Pittsboro, NC

Here’s some pros, cons and inside information to help find the best direction for your specific situation.

Going the Insurance route and meeting coverage:

Insurance will cover a power chair or scooter if you meet the medical criteria AND your physician is willing to complete the paperwork the way your plan requires it. The days of getting equipment by your MD writing an Rx his way and verbally telling you that you need one are long gone!! The current Rx must have 7 elements written a certain way and the MD must complete it in its entirety himself, all in his handwriting. The exam must address a dozen or so specific issues in detail as well. If one detail is too general or omitted, the insurance will deny.

Here’s the simplified medical criteria list that must be met: You must have difficulties getting around inside your home with daily activities like getting to the bathroom in a timely manner, being able to fix a meal, get dressed, home maintenance, etc., and you are not able to safely utilize a cane, walker or manual push wheelchair to complete these tasks.

Examples of cases who should meet the criteria:

• a person who has had a stroke and can no longer use an arm and leg
• someone with severe breathing issues and shortness of breath
• someone with severe neuropathy or who has a history of falls and reduced upper body function
• someone whose MD will willing to properly follow ALL the insurance rules

Examples of cases who would not meet the criteria:

• a leg amputee with good upper body strength who can push a manual chair
• someone who needs help for outside activities only (getting their mail, shopping, MD appointments) and gets around fine inside with a cane or walker
• if there’s not enough space in your home for use of equipment
• someone whose MD does not closely follow the insurance paperwork rules

Lift Chairs through insurance:

Insurance will cover the lift mechanism only: In order to qualify, you have to have very specific medical conditions that hinder getting up from a standard height seat but then you must be able to walk. Click here for details. Insurance does not cover the cost for the rest of the chair. Doesn’t seem to make sense but that’s the rule.

Pros: In most cases, there is Little or No cost to you on power chairs, scooters and the lift mechanism part of the lift chair if you also have a paying secondary (supplemental) coverage. The lift mechanism cost on a Lift Chair, averages around $275. If you do not have a secondary / supplement coverage, you are responsible for any unmet deductibles or co-insurance.

Cons:

• You have to meet strict criteria, especially with Medicare, in order to be approved. You must make a new, specific appointment with your MD for a face to face mobility exam. Some insurances like Blue Cross Blue Shield require a separate Physical Therapy exam for a power chair or scooter along with the MD exam.
• The process can take 3-6 weeks or more.
• The insurance claim department or an insurance reviewer may not feel you meet the criteria or may deny coverage for issues that are related to technicalities.

Inside Info:

• Medicare has recently cut reimbursement in half for many products so if you are approved for a power chair or scooter, providers will only be able to supply a limited selection of basic equipment. Features that most people want like larger batteries and tires, custom sized seat or a drink holder are considered “luxury” options and not covered or available through insurance. Some providers have chosen to not provider scooters through insurance, since the reimbursement is now so low, the quality level of the scooter would have to be lowered in order to meet the current reimbursement levels that are now half.
• If you live in a Medicare CBA (Competitive Bid Area), click here for details, you can only get approved for equipment though a select group of low bidding winners from a list with Medicare. Call 1-800-MEDICARE for details.

Going the Cash Route

You can get exactly what you want without meeting any medical criteria and without seeing your physician. You are not limited to basic equipment that is coded/ allowed by insurance. New and innovative choices like the Transformer auto-folding scooter, the Golden Technology Day Dreamer with a power adjustable head pillow and  Jazzy Air with a 10” motorized seat lift are now available to you.

Pros: You can quickly obtain and start using your equipment within a week or so. Some products are available same day depending on your location and the specific model you are interested in. You do not have to make an addition appointment to see your MD or get them involved at all.

You have a world of helpful accessory options available to make your daily activities more enjoyable (drink and phone holders, larger batteries for extended range, full suspension for a smoother ride, etc).

Most providers do offer credit card options and financing. If your credit score is in the mid to upper 500 range, you should be eligible for financing.

Cons: You are purchasing it yourself.

Insider Info: Equipment manufacturers like Jazzy, Pride, Golden Technologies, Solax, Merits, and Drive Medical, in order to adjust to the dramatic changes in the mobility industry have evolved into two distinct directions.

*The first is for the insurance cases with the lower reimbursement prices for providers. Equipment has been streamlined and re-designed specifically to reflect daily inside the home use. Larger knobby tires, bigger batteries and higher ground clearances are no longer incorporated.

*The second direction is for cash purchases. These units are designed for inside or purely outside use and are available with tons of options. Options include super lightweight foldable units for travel, upgraded suspension, deluxe seating, head and tail lights, turning signals, over-sized knobby tires, higher speeds, high ground clearances for off road surfaces, extended range batteries and more.

Still need help deciding which way to go or need more details? Call us at 1-800-681-8831 or visit our NEW retail showroom in Raleigh NC, at 1829 Capital Blvd, Ste 103. 27604