BACKGROUND

Service delivery of complex rehabilitation technology (CRT) is an eight-step process outlined in the RESNA Wheelchair Service Provision Guide, highlighting steps from referral and assessment by clinicians and providers to delivery of the wheeled mobility device (WMD) (Arledge et al., 2011). A scoping review performed by an interdisciplinary team from the University of Pittsburgh, The Ohio State University, and University of Michigan investigated CRT service delivery practices, resulting in a collection of peer-reviewed articles from a range of countries, clinical environments, and funding sources (Betz et al., 2021). This scoping review identified barriers and facilitators to past and current service delivery practices and identified common themes in the literature, of which "policy" was a central result. An in-depth investigation into policies that regulate the provision of wheeled mobility devices is needed to supplement the results of the scoping review.

The policies that regulate wheeled mobility device provision vary in interpretation and implementation across clinical settings and payor sources. In the United States, the Center for Medicare and Medicaid Services (CMS) is the primary driver behind wheeled mobility device policy. Private insurance companies often use CMS guidelines to create their own mobility device provision policies. Alternatively, the Veteran's Health Administration (VHA) is a unique system which acts as both the provider and the payor of assistive technologies. The policy documents for each of these entities are examined.

The goal of this investigation is to examine policy language, identify commonalities and differences between policies, and extract relevant themes. This on-going investigation will be used to support efforts by the Disability and Rehabilitation Research Projects (DRRP) Program: Research on Healthcare Policy and Disability to create and implement a novel CRT service delivery policy that promotes value-based care, improved health outcomes, and satisfaction for wheeled mobility device users.

METHODS

The team searched through the results of the scoping review and selected articles with the themes of policy, Medicare, or Medicaid (Betz et al., 2021). A full-text review and data extraction for each article was performed to identify relevant information. These data categories include the country or state the article originated in, a population description, the type of mobility devices addressed (i.e., manual wheelchair, power wheelchair, scooter, other), device service and maintenance coverage, device use for "in-the-home" only, and potential themes.

State Medicaid policies were evaluated, including Alaska, California, Colorado, Florida, Georgia, Illinois, Michigan, Ohio, Oregon, Pennsylvania, and Texas. These states were chosen by internal project stakeholders and subject matter experts as a sample of the US. Categories of extracted information included the type of mobility device that's covered, if device service and maintenance are covered, and potential themes.

The team investigated mobility device policy for private insurance companies, including United Healthcare, Blue Cross Blue Shield, Anthem, Cigna, Humana, Kaiser Permanente, Centene and Health Care Service Corporation. The strategies for locating official policy documents included search phrases such as "wheelchair provision policy insurance", "(insurance company) wheelchair coverage policy" and "(insurance company) durable medical equipment (DME) policy". Each private insurance website was individually searched if the documents could not be located with an internet search.

The final category examined was WMD policy for the VHA under the Prosthetics and Sensory Aids Service. The most recent policy documents were investigated including the VHA Directive for Wheeled Mobility Devices, as well as Prosthetic and Rehabilitative Items and Services: A Rule by the Veterans Affairs Department. The team analyzed policy language to identify themes as well as similarities and differences with other US based WMD policies.

RESULTS & DISCUSSION

There were 30 peer-reviewed articles from the initial scoping review that addressed wheeled mobility device policies. Twelve articles were from a range of countries including Australia, Canada, Columbia, Denmark, Kenya, Norway, Philippines, Singapore, South Africa, and the United Kingdom. The remaining 18 articles investigated US states including Washington, Georgia, New York, and Ohio. These papers addressed a range of information on wheelchair service provision policy that fell into several distinct categories. The first category is articles that addressed the gaps between policy documentation and actual service delivery that negatively impact end-users (Boss & Finlayson, 2006; L. J. Cohen & Perling, 2015; Eggers et al., 2009; Pedersen et al., 2014; Smith et al., 2018; Sneed, 2004; Sund et al., 2013; Toro-Hernández et al., 2019; Visagie et al., 2013). Articles also addressed common challenges with navigating existing funding policies or accessing alternative funding sources (Bamer et al., 2010; Gallagher et al., 2020; Paguinto et al., 2020; Sanderson & Place, 2001; Smith et al., 2018; Sund et al., 2013; White, 1998). In addition, there is a lack of standardized methods for identifying consumer needs and eligibility criteria for acquiring CRT, including the ambiguity in defining "medical necessity" in current policy (Anslow, 1998; Dicianno & Tovey, 2007; Eagles, 1996; Ferguson-Pell et al., 2005; Stanley, 2015; Wolff et al., 2005). The need to operationalize and standardize data collection for assistive devices is needed to support the development of evidence-based coverage policies (L. Cohen et al., 2013; Sheldon & Jacobs, 2007). Options for identifying optimal mobility devices may be limited, impacting consumers' need for highly individualized products (Groah et al., 2014; Margolis, 2021; Pedersen et al., 2014; Stanley, 2015; Williams et al., 2017). Additionally, current policy incentivizes a focus on profit margins ahead of positive patient care (Goodwin et al., 2007; Groah et al., 2014). A significant number of articles describe Medicare's "in-the-home" restriction, which restricts the consumers ability to be active participants in their work, school, and community (Medicare Rights Center, 2005). Alternatively, the VHA does not have a home restriction for device use, thereby promoting community participation for their veterans (Hubbard Winkler et al., 2010). One article that stood out described the Independence Care System in New York, which combined Medicare and Medicaid funding into a fully integrated health insurance plan that showed overall healthcare savings when functional needs are prioritized (Minkel, 2015). A resulting theme is although there are policies and guidelines in place, specific consumer clinical needs cannot always be met. There is a need for policy that is clear and standardized regarding the qualification for and coverage of wheeled mobility devices.

The research team investigated 8 state Medicaid policies for language related to the provision, maintenance, and replacement of wheeled mobility devices. In these policies, manual wheelchairs, power wheelchairs, scooters, seating, and accessories are all addressed (Alaska State Legislator, 2021; Colorado Department of Health Care Policy & Financing, 2022; Florida Agency for Health Care Administration, 2010; Illinois Department of Healthcare and Family Services, 2015; Medi-Cal, 2020; Michigan Department of Health and Human Services, 2022; Oregon Health Plan, 2020; Texas Medicaid, 2022).There are many commonalities and few differences between state Medicaid policies. For example, a similarity throughout Medicaid policy, the same as Medicare, is the definition of medical necessity for a wheeled mobility device. This definition varies slightly state to state, but overall includes assisting an individual to achieve or maintain maximum functional capacity in performing one or more activities of daily living, to protect life and prevent significant illness, injury, or pain, and be consistent with generally accepted professional medical standards. CMS policies use Healthcare Common Procedure Coding system (HCPCS) to classify technology and require a licensed/certified medical professional (LCMP) to prescribe devices. In contrast to the Medicare policy that restricts the use of WMD in the home, Medicaid policies include the community environment in this definition for ADLs.

Similarities and differences among the state Medicaid policies address the prescription process, maintenance and repair process, and the categorization of WMD. All policies require the WMD prescription must come from a physician, nurse practitioner, clinical nurse specialist, or physician's assistant. One of the differences between states is how maintenance and repairs are managed. Most states only cover extensive servicing that is performed by authorized technicians, and not routine maintenance. However, in Florida and Michigan both routine maintenance and major repairs are reimbursed services (Florida Agency for Health Care Administration, 2010; Michigan Department of Health and Human Services, 2022). Replacement of the device is warranted if repairs cost more than 75% the price of a new device, as is the case for most states. Another difference is Colorado Medicaid may cover a secondary device for use in scenarios in which an individual's primary device is inadequate (Colorado Department of Health Care Policy & Financing, 2022). There is variability among states on the rental period before the device is considered purchased, ranging from 10 to 13 months. Some states lump together complex rehabilitation technology with prosthetics and orthotics, making it difficult to ascertain specific applications for wheeled mobility devices (Alaska State Legislator, 2021). Overall, Medicaid policies are very similar with only small differences that are not particularly noteworthy when evaluating US CRT service delivery policy broadly.

For private insurance companies, there is a significant amount lot of overlap with CMS CRT policy. This included definitions of medical necessity, assessment, and prescription by a licensed medical professional, and that backup chairs, Group 4 power wheelchairs, and power seat elevator are not considered medically necessary (Aetna, 2021; Anthem, 2021a, 2021b, 2021c; BlueCross BlueShield of North Carolina, 2021; Centene, 2021; Cigna, 2021; HCSC, 2018; Humana, 2021; Kaiser Permanente Health Plan of Washington, 2021; United Healthcare, 2021). There are small differences between insurances on the coverage of routine maintenance versus extensive repair, typically only extensive repair is reimbursed. Based on the specific plan for a beneficiary, the percentage of the covered item owed by the customer can range from 0-35%(Cigna, 2021). Most of these policies also highlight the "5-year rule", in which a device will not be replaced before five years unless there is a change in the member's physical condition, or the wheelchair is inoperable and cannot be repaired at a cost less than a rental or replacement. There are minor differences between insurance companies' policies on the provision of mobility devices.

VHA policy is different in that the requirements to qualify for a mobility device, receive the appropriate parts and accessories for that device, and receive more than one device are more accessible. The VHA considers quality of life an important factor when determining medical necessity for prescribing for a wheeled mobility device (Department of Veterans Affairs, 2021). This could include the provision of adaptive sports technology, which supports "quality of life opportunities that are uniquely presented by recreation, like personal enjoyment and fulfillment, and socialization with friends, family, and fellow veterans" (Federal Register, 2020). Additionally, there is discussion on the consideration of comfort and convenience when prescribing mobility devices. Unlike other payor sources, the VHA believes comfort and conceive should be an important consideration when comparing multiple devices to identify the optimal one for a veteran. Common themes amongst all US policies are the discussion around the definition and qualification for medical necessity, and the involvement of an experienced LCMP. Comments suggest the VA struggles with the definition of medical necessity and therefore should not be considered when providing prosthetic or rehabilitative items or services (Federal Register, 2020). However, policy clearly states that durable medical equipment is expressly listed as medical services that "promote, preserve, or restore the health of the individual and is in accord with the generally accepted standards of medical practice" (Federal Register, 2020). This policy is important to evaluate as it models an alternative payor system.

CONCLUSION & FUTURE WORK

This investigation identified common policy language, current regulations, and coverage criteria for wheeled mobility devices. Extracted themes include definitions of medical necessity, the use of HCPC coding for CMS and private insurances, and LCMP required to perform assessments in all US policies. Private insurance companies' guidelines are very similar to Medicare, specifically the restriction of device use for in the home. Both Medicaid policy and VHA policy consider community interaction a part of performing ADLs, so WMD are covered for use outside of the home. VHA policy is different in that quality of life and secondary devices for community and social interaction are covered. This broad investigation of policy provides clarity and understanding of current language, and the similarities and differences between payor sources. The information from this review will be used to supplement current and future research projects with the goal of creating and implementing an updated CRT service delivery policy.