Private insurance companies are typically for-profit organizations. Each company develops their own policies and regulations regarding durable medical equipment (DME) coverage. That is what can make the funding process so confusing. Despite the autonomy, more and more insurance plans are using Medicare policies as the standard to follow in development of their own programs.
It is very important you get your insurance handbook. If you do not have it anymore, you can follow the links below for more information. Also, this is where it is essential you find out what your insurance company has stated in writing regarding coverage of wheelchairs. It is up to you to know about your insurance plan. Remember, knowledge is power.
Each insurance company has its own policies and procedures. Check to see if pre-approval is necessary and what the covered benefits are regarding Durable Medical Equipment (DME), wheelchairs specifically. You can find this out from your insurance handbook, searching your insurance company's website or by calling member services. NOTE: There may be different policies within the same company – so it is best to look at your individual policy in your insurance handbook or on the website provided to you by member services.
It is important to know what the insurance company says about wheelchairs for yourself. You may have great benefits or you might have a "cap" on the dollar amount that can be used towards your wheelchair. Find out what your insurance company and personal plan pays for and to what amount.
A co-payment is a flat dollar amount or a percentage paid for a medical service. If you are required to pay a percentage co-payment, that number is based off of the allowable for your insurance company and supplier agree upon, not the actual equipment retail cost. For example, if your wheelchair retails for $7,000.00 but your insurance allowable, is set at $5,342.00, the allowable is the largest amount that can be billed. That billed amount is then used to calculate your co-payment. Meaning, if you had a 20% co-payment, the amount you owed would be calculated from the $5342.00 resulting in $1068.40 that you owned. No matter what the retail cost is, the allowable determines your cost.
If you are unsure what your co-pay is or your percentage check your insurance handbook, insurance card or call member services to see if a co-payment will be required for your wheelchair.
Each insurance company has its own definition of medical necessity. It is imperative for you to know your insurance company's definition and qualifiers for you to be eligible for a wheelchair. There are many ways to find out your insurance companies definition, check your insurance handbook, search their website or call your member services.