In the state of Ohio, patients who reside in skilled nursing facilities (also known as long-term care facilities) and are covered by Ohio Medicaid or a My Care Ohio Medicaid Plan (Molina My Care, Aetna Better Health and Buckeye My Care for our areas) and are in need of custom wheelchair have the benefit available to have the custom wheelchair provided to them by a DME company. In January 2014, the state of Ohio changed the bundled definition of what the skilled nursing facilities are required to supply for a skilled nursing home resident. Several services were unbundled and allowed for outside vendors to supply and bill for their services. Custom wheelchairs are one of those services.
What makes a wheelchair custom in the eyes of Ohio Medicaid?
What makes a wheelchair custom is the seating system. The seating system consists of custom made back and seats cushions specifically measured and tailor made specifically for an individual with moderate to severe postural asymmetries that cannot be corrected or fitted to the individual with any off the shelf planar back and seat cushion. This seating system is made for a specific individual and cannot be used for any other resident. The chair obviously comes with the custom seating system as you cannot have a custom seating system with no chair.
What types of chairs do we do?
We provide manual light weight manual wheelchairs, high strength light weight manual wheelchairs, ultra light weight manual wheelchairs, tilt in space manual wheelchairs, complex rehab power wheelchairs that may have static seating (do not have power seating), complex rehab power chairs with powered seating(tilt, tilt recline, power elevating leg rests) and heavy duty power wheelchairs. Each of these chairs
will have custom seating which make them eligible for the Medicaid custom wheelchair benefit.
What qualifies residents of a skilled nursing facility to receive a custom wheelchair?
As stated earlier, the resident must have a moderate to severe postural asymmetry to qualify. Postural asymmetries include Kyphosis, Scoliosis, Lordosis which are curvatures of the spinal column. As well as pelvic asymmetries such as pelvic obliquities, rotations, anterior or posterior pelvic tilt and limited hi flexion. Kyphosis
– Is a curvature usually in the thoracic or sacral area of the spine, also known as the widow's hump, which can be severe enough to cause hyper extension of the neck to compensate for the inability to see their surrounding. Lordosis
– Is an inward curvature of the cervical and lumbar regions of the spines. When seated, a resident with significant lordosis, you will see that even seated all the way back in a chair, only the thoracic (upper back) and hips/buttocks are making significant contact with the back of the chair. Scoliosis
– A sideways curvature of the spine. The curve is often referred to as a C or S shape. The severity of the scoliosis is noted and support is placed to correct or prevent further curvature. C
– support is placed First support is placed at the top of the curve, second at the apex or slightly below and the third at the pelvis to prevent shifting. S
– support is placed laterally at the apex (farthest point out laterally from the midline of the body) of each curve Pelvic Obliquities
– Occurs when one side of the pelvis is higher than the other. You will see that when a resident is seated, one side of the hip will he higher, meaning the seating load on IT of the lower side in a flexible situation is bearing more of the weight while sitting. This can be corrected by raising the lower side of the obliquity. Pelvic rotation
– Occurs when one side of the pelvis is rotated forward and can cause a minimal to significant leg length discrepancy while seated. Anterior pelvic tilt
– Is when the front (anterior) of the pelvis drops and the back (posterior) rises, the hip flexors shorten and hip extensors lengthen, this can cause an increase in spinal lordosis as the resident tries to sit upright. Posterior pelvic tilt
– Is when the front (anterior) rises and the back (posterior) drops, the hip flexors lengthen and hip extensors shorten. This can cause the patient to look as though they are sliding forward in the wheelchair.
What does Medicaid consider to be moderate or severe enough for custom seating?
Good question!! It is up to the ordering team to justify that standard planar seating will not suffice for the resident. Medicaid will want to know if the asymmetries are fixed or flexible, what are the degrees or measurements of the curvatures or rotations. All of this must be clearly noted on the ODM 03411 Ohio Medicaid form. It is not an exact science and the insurance asks for a little more each and every day.
What plans cover these chairs?
Traditional Ohio Medicaid and the My Care Ohio Medicaid plans. The plans in our areas are Aetna Better Health and Molina My Care in Cincinnati and Molina My Care and Buckeye in Dayton.