Rule 23-207-3.11 - Individualized, Resident Specific Custom Manual and/or Custom Motorized/Power Wheelchairs Uniquely Constructed or Substantially Modified for a Specific ResidentA. The Division of Medicaid defines a wheelchair as a seating system that is designed to increase the mobility of residents who would otherwise be restricted by inability to ambulate or transfer from one place to another. B. The Division of Medicaid defines an individualized, resident specific custom manual and/or custom motorized/power wheelchair as one that has been uniquely constructed or substantially modified for a specific resident referred to in this Rule as "custom manual wheelchair" and/or "custom motorized/power wheelchair." C. The Division of Medicaid does not classify the following wheelchairs as custom manual and/or custom motorized/power wheelchairs: 1. Standard manual wheelchairs, 2. Standard manual wheelchairs with added accessories, 3. Standard motorized/power wheelchairs, and/or 4. Standard motorized/power wheelchairs with added accessories. D. The Division of Medicaid covers custom manual and/or custom motorized/power wheelchairs and accessories for rental up to the purchase price or purchase when: 1. Medically necessary with comprehensive documentation that a standard wheelchair cannot meet the resident's needs and the resident requires the custom manual and/or custom motorized/power wheelchair for six (6) months or longer, 2. Ordered by a pediatrician, orthopedist, neurosurgeon, neurologist, or a physiatrist, 3. Not primarily used as a restraint, and 4. Prior authorized by a Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity. E. The Division of Medicaid requires the following documentation for a custom manual and/or custom motorized/power wheelchair. 1. A face-to-face evaluation by a pediatrician, orthopedist, neurosurgeon, neurologist, or a physiatrist who is prescribing the custom manual and/or custom motorized/power wheelchair which includes, but is not limited to: a) The reason for the evaluation visit is a mobility examination, b) If the resident currently possesses a custom manual and/or custom motorized/power wheelchair not previously purchased by the Medicaid program. c) A certificate of medical necessity with comprehensive documentation that describes the medical reason(s) why a custom manual and/or custom motorized/power wheelchair is medically necessary such that no other type of wheelchair can meet the needs of the resident including, but not limited to: 1) The diagnosis/co-morbidities and conditions relating to the need for a custom manual and/or custom motorized/power wheelchair. 2) Description and history of limitation/functional deficits. 3) Description of physical and cognitive abilities to utilize equipment. 4) History of previous interventions/past use of mobility devices. 5) Description of existing equipment, age of equipment and specifically why it is not meeting the resident's needs. 6) Explanation as to why a less costly mobility device is unable to meet the resident's needs. 7) Description of the resident's ability to safely tolerate/utilize the prescribed custom manual and/or custom motorized/power wheelchair. 8) The type of custom wheelchair and each individual attachment and/or accessory required by the resident. 2. An initial evaluation by a physical therapist (PT) or occupational therapist (OT), not employed by the Durable Medical Equipment (DME) provider or the manufacturer, within three (3) months of the date of the written prescription to determine the individualized needs of the resident which includes whether the resident currently possesses a custom manual and/or custom motorized/power wheelchair not previously purchased by the Division of Medicaid at the time of the initial evaluation. 3. An agreement by both the prescribing physician and the PT or OT performing the initial evaluation that the individualized equipment being ordered is appropriate to meet the needs of the resident. 4. A subsequent evaluation after the delivery of the custom manual and/or custom motorized/power wheelchair by a PT or OT, not employed by the DME provider or the manufacturer, to determine if the custom manual and/or custom motorized/power wheelchair is appropriate for the resident's needs. 5. The PT/OT initial and subsequent evaluations must include the appropriate seating accommodation for the resident's height and weight, specifically addressing anticipated growth and weight gain or loss. F. The Division of Medicaid covers a custom motorized/power wheelchair only when a custom manual wheelchair cannot meet the needs of the resident. The resident must meet the following criteria: 1. Be bed/chair confined with documented severe abnormal upper extremity dysfunction or weakness, 2. Expect to have physical improvements or the reduction of the possibility of further physical deterioration from the use of a custom motorized/power wheelchair, 3. Be for the necessary treatment of a medical condition, 4. Have a poor prognosis for being able to self-propel a functional distance, 5. Not exceed the weight capacity of the custom motorized/power wheelchair prescribed, 6. Have sufficient eye and/or hand perceptual capabilities to operate the custom motorized/power wheelchair safely, 7. Have sufficient cognitive skills to understand directions, such as left, right, front, and back, and be able to maneuver the motorized/power wheelchair in these directions independently, 8. Be independently able to move away from potentially dangerous or harmful situations when seated in the custom motorized/power wheelchair, 9. Demonstrate the ability to start, stop, and guide the custom motorized/power wheelchair within a reasonably confined area, 10. Be in an environment conducive to the use of the custom motorized/power wheelchair. a) The environment must have sufficient floor surfaces and sufficient door, hallway, and room dimensions for the custom motorized/power wheelchair to turn and enter and exit, as well as necessary ramps to enter and exit the ICF/IID. b) The environmental evaluation must be documented and signed by the resident/caregiver and DME provider for the custom motorized/power wheelchair. G. The Division of Medicaid covers a customized electronic interphase device, specialty and/or alternative controls if the resident is unable to manage a custom motorized/power wheelchair without the assistance of said device. The Division of Medicaid requires documentation of an extensive evaluation of each customized feature required for physical status and specification of the medical benefit of each customized feature. 1. For a joystick, the resident must demonstrate safe operation of the custom motorized/power wheelchair with an extremity, such as the hand or foot, using a joystick hand or foot operated device. The resident can manipulate the joystick with fingers, hand, arm, or foot. 2. For a chin control device, the resident must demonstrate safe operation of the custom motorized/power wheelchair with manipulation of the chin control device. The resident must have a medical condition which prevents the use of their hands/arms but is able to move their chin and safely operate the chair in all circumstances. 3. For a head control device, the resident must demonstrate safe operation of the custom motorized/power wheelchair with manipulation of the head control device. The resident must have a medical condition which prevents the use of their hands/arms but is able to move their head freely with control of their head and can safely operate the chair in all circumstances. 4. For an extremity control device, the resident must demonstrate safe operation of the custom motorized/power wheelchair with manipulation of the extremity control device. The resident must have a medical condition which prevents or limits fine motor skills during the use of their extremities but is able to move their hands/arms/legs to safely operate the chair in all circumstances. 5. For a sip and puff feature, the resident must demonstrate safe operation of the custom motorized wheelchair with manipulation of the sip and puff control. The resident cannot move their body at all and cannot operate any other driver except this one. H. Custom manual and custom motorized/power wheelchairs are limited to one (1) per resident every five (5) years based on medical necessity. Reimbursement: 1. Is made for only one (1) custom manual and/or custom motorized/power wheelchair at a time. 2. Includes all labor charges involved in the assembly of the wheelchair and all covered additions, accessories and modifications. 3. Includes support services such as emergency services, delivery, setup, education and ongoing assistance with use of the wheelchair. 4. Is made only after the PT or OT subsequent evaluation is completed. I. The DME provider must ensure the prescribed custom manual and/or custom motorized/power wheelchair and accessories are adequate to meet the resident's needs, must ensure the proper height and width, and must provide an automatic or special locking mechanism for residents unable to apply manual brakes. J. The DME provider providing custom motorized/power wheelchairs to residents must: 1. Have at least one (1) employee with Assistive Technology Professional (ATP) certification from Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) who specializes in wheelchairs and who must be registered with the National Registry of Rehab Technology Suppliers (NRRTS). a) The NRRTS and RESNA certified personnel must have direct, in-person, face-to-face interaction and involvement in the custom motorized/power wheelchair selection for the resident. b) RESNA certifications must be updated every two (2) years. c) NRRTS certifications must be updated annually. d) If the certifications are found not to be current, the prior authorization request for the motorized/power wheelchair will be denied. 2. Provide a lifetime warranty on the powered mobility base frame against defects in material and workmanship for the lifetime of the resident. 3. Provide a two (2) year warranty of the major components, beginning on the date of delivery to the resident. a) The main electronic controller, motors, gear boxes and remote joystick must have a two (2) year warranty from the date of delivery. b) Cushions and seating systems must have a two (2) year warranty or full replacement for manufacturer defects or if the surface does not remain intact due to normal wear. 4. If the DME provider supplies a custom motorized/power wheelchair that is not covered under a warranty, the DME provider is responsible for any repairs, replacement or maintenance that may be required within the two (2) years. K. DME providers providing custom motorized/power wheelchairs, customized electronic interphase devices, specialty and/or alternative controls for wheelchairs, extensive modifications and seating and positioning systems must have a designated repair and service department, with a technician available during normal business hours, between eight (8:00) a.m. and five (5:00) p.m. Monday through Friday. Each technician must keep on file records of attending continuing education courses or seminars to establish, maintain and upgrade their knowledge base. L. The Division of Medicaid covers repairs, including labor and delivery, of a custom manual and/or custom motorized/power wheelchair owned by the resident not to exceed fifty percent (50%) of the maximum allowable reimbursement for the cost of replacement. 1. The ICF/IID is responsible for the repairs, including labor and delivery, of custom manual and/or custom motorized/power wheelchairs delivered to the resident prior to January 2, 2015. 2. Major repairs and/or replacement of parts require prior authorization from a UM/QIO, the Division of Medicaid, or designated entity and must include an estimated cost of the necessary repairs, including labor, and documentation from the practitioner that there is a continued need for the custom manual and/or custom motorized/power wheelchair. 3. An explanation of time involved for repairs and/or replacement of parts must be submitted to a UM/QIO, the Division of Medicaid, or designated entity. 4. Manufacturer time guides must be followed for repairs and/or replacement of parts. 5. The Division of Medicaid defines repair time as point of service and does not include travel time to point of service. 6. No payment is made for repairs or replacement if it is determined that intentional abuse, or misuse, of the wheelchair or components has occurred. This includes damage incurred due to inappropriate covered transportation for the prescribed custom manual and/or custom motorized/power wheelchair. 7. Reimbursement will be made for up to one (1) month for rental of a wheelchair while the resident's wheelchair is being repaired. 8. The Division of Medicaid does not cover the repair of a rented custom manual and/or custom motorized/power wheelchair. 23 Miss. Code. R. 207-3.11
42 U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117, 43-13-121.