Frequently Asked Questions

In December 2014, the Centers for Medicare and Medicaid Services (CMS) posted on the Web a “Frequently Asked Questions” (FAQ) document stating that when it implements its authority to apply bid rates in non-bid areas starting in January 2016, it will apply bid rates to certain complex rehab accessories (such as seat/back cushions, recline/tilt systems, or specialty controls) that have never been included in the Medicare DME bidding program. This announcement came as a shock to anyone familiar with the 2008 Medicare Improvements for Patients and Providers Act Congress, which excluded from the bid program complex rehab power wheelchairs and the accessories provided with them. Further, subsequent to and in the same spirit as the MIPPA exemption, CMS excluded complex manual wheelchairs and implemented a similar policy for accessories used with these wheelchairs. As a result, complex rehab wheelchairs and related accessories have continued to be paid at the established fee schedule amounts in bid and non-bid areas.

The December 2014 CMS FAQ followed CMS’ November 2014 final regulation implementing its authority to use information from the bidding program to adjust rates in non-bid areas starting January 2016. The final regulation details how CMS will use this information to reduce the Medicare fee schedule for bid-program items provided in non-bid areas.

The problem stems from the fact that the HCPCS codes are very broad. A single HCPCS code can encompass many wheelchair accessories, from standard, typically provided items to very complex accessories with relatively small utilization. Wheelchair accessory HCPCS codes were included in the bid program since the more “standard” accessories were included. Arguably, the bid price reflects the cost of providing the standard item, not the more complex accessories that were not included in the program.

CMS plans to apply the bid price for the standard item to the complex accessories, simply because a single HCPCS code includes a variety of accessories.

If complex rehab accessories had their own HCPCS codes (as in the Ensuring Access to Quality Complex Rehabilitation Services” bill, HR 1516), CMS wouldn’t be able to reduce the fee schedules for complex wheelchair accessories. How will we fix this problem? First, we are working with several members of Congress to exert political pressure on CMS to rescind the policy. Six representatives have drafted a letter asking CMS to rescind this decision, and are circulating the letter to all representatives, asking for signatures. The representatives spearheading the effort are all on House committees with jurisdiction over Medicare DME policy.

At press time, the letter had garnered 88 signatures. The congressional letter to CMS states: “We are concerned about the potential negative impact on Medicare beneficiary access to complex rehabilitative wheelchairs and the important accessories used with these devices. A preliminary review of the affected codes indicates that a shift from the current fee schedule to bid program pricing could cut reimbursement to suppliers by 20 to 50 percent. Complexrehabilitative power and manual wheelchairs and the related accessories described above are used by people with serious disabilities including amyotrophic lateral sclerosis (ALS), cerebral palsy, multiple sclerosis, muscular dystrophy, spinal cord injury, and traumatic brain injury. This small population of Medicare beneficiaries with significant disabilities depend on these individually configured products to meet their unique medical needs and maximize their function and independence.”

“For the reasons discussed above, we urge CMS to review its decision to issue its December 2014 FAQ. We also request that CMS issue written clarification that accessories used with complex rehabilitative power and manual wheelchairs will continue to be paid at Medicare established fee schedule amounts and that such amounts will not be adjusted based on Medicare competitive bidding program pricing.”

If CMS chooses not to fix this problem pursuant to this congressional request, we will have to seek help via legislation that would clarify Congress’ original intent to not include complex wheelchairs in the DME bidding program. If you provide CRT items, you need to educate your members of Congress about this issue. Find more information at access2CRT.org.