|
These comments are being submitted on behalf of a national, consumer-led
coalition known as the “ITEM” Coalition, an acronym for Independence Through
Enhancement of Medicare and Medicaid. The ITEM Coalition was formed in
2003, and its 74 member organizations include a diverse set of disability
groups, aging organizations, other consumer groups, labor organizations,
voluntary health associations, and non-profit provider associations.
The ITEM Coalition’s purpose is to raise awareness and build support for
policies that will improve access to assistive devices, technologies, and
related services for people of all ages with disabilities and chronic conditions.
From coverage for hearing aids to augmentative communications devices (AACs)
to advanced artificial limbs to screen readers for people with vision impairments,
the Coalition’s mission is a broad one with implications for virtually
every person with a disability who relies on assistive devices to be healthy,
functional, and independent.
The following comments address the draft Local Coverage Determinations
(LCD) for Power Mobility Devices (PMDs) as released by the Durable Medical
Equipment Regional Carriers (DMERCs) on September 14, 2005. We hope that
the DMERCs will seriously consider these and all comments representing
the input of stakeholders when crafting the final LCDs.
I. “In the Home” Restriction
Removal of the “In the Home” Restriction
The ITEM Coalition strongly opposes the continued use of Medicare’s “in
the home” restriction on mobility devices. The Centers for Medicare and
Medicaid Services (CMS) confine coverage of mobility devices to those that
are medically necessary within the patient’s home. This restriction prevents
many Medicare beneficiaries with disabilities from participating in important
activities that routinely take place outside the home such as working,
attending school, going to the grocery store and back, attending religious
services, and going to the physician’s office. The perpetuation of this
rule leaves many Medicare beneficiaries without access to mobility devices
necessary to lead healthy and independent lives.
Earlier this year, over 100 Members of Congress wrote to the Secretary
of Health and Human Services (HHS) to request that the Department modify
its current interpretation of the “in the home” restriction to improve
community access for Medicare beneficiaries with disabilities. Additionally,
the letter states that if HHS concludes that it does not have the authority
to modify this restriction, that it inform Congress of such a decision
so that Congress may begin considering legislative alternatives. As of
today, those Members of Congress have not received responses to their letter.
Despite over 130 comments requesting changes to the “in the home” restriction
submitted during the comment period on the draft National Coverage Determination
(NCD) for Mobility Assistance Equipment (MAE), CMS stated that the NCD
would not be the appropriate place to address the “in the home” restriction.
However, the agency failed to state the appropriate mechanism for addressing
this restriction.
Medicare beneficiaries are now faced with a draft LCD that further codifies
CMS’ and the DMERCs’ use of to this restrictive interpretation of the Medicare
statute. In fact, ITEM Coalition members are concerned that the draft LCD
worsens the impact of the “in the home” requirement by unnecessarily interspersing
the phrase throughout the LCD document and confining the functional coverage
criteria to in-home activities only.
“In the Home” Need as Coverage Trigger
The ITEM Coalition members will continue to oppose the “in the home” restriction
but recognize that as we suggest changes to the draft LCD, we must do so
in the confines of the NCD standards which state that only those who need
a mobility device for activities in their home are eligible for coverage.
Therefore, coalition members are requesting that the DMERCs consider interpreting
the “in the home” restriction in an alternate way that we believe is consistent
with the NCD but also comes closer to meeting the needs of beneficiaries
with disabilities.
The ITEM Coalition requests that the DMERCs restructure the draft LCD in
a way that employs the “in the home” criterion as a trigger to Medicare
coverage, yet allows Medicare to assess an individual to identify and treat
the full complement of their functional needs, both inside and outside
of the home. In other words, we urge the DMERCs to allow Medicare coverage
for those devices that are not only reasonable and necessary for the completion
of MRADLs inside the home, but also appropriate for the completion of activities
outside the home, once it is determined that the beneficiary meets the
“in the home” criteria.
For example, Beneficiary “A” is an individual with Multiple Sclerosis who
is unable to ambulate into the kitchen to cook or the bathroom to bathe.
After a clinical assessment, it is clear that Beneficiary “A” is eligible
for a mobility device due to her “in the home” need. However, while she
is able to move about her home with a manual wheelchair, Beneficiary “A”
also has a need to attend religious services and is not able to do so without
a power wheelchair. The clinician determines that the beneficiary would
be able to use the power wheelchair around her home to complete MRADLs.
Therefore, we believe that the beneficiary should be eligible for Medicare
coverage of the power wheelchair. This interpretation of the “in the home”
restriction would still guarantee that mobility devices could be used to
complete MRADLs in one’s home, but could also be appropriate for other
activities outside the home.
II. Mobility Related Activities of Daily Living
Definition of MRADLs:
The ITEM Coalition strongly disagrees with the DMERCs’ choice to definitively
define mobility-related activities of daily living (MRADLs) as toileting,
feeding, dressing, grooming, and bathing.
The final NCD states that “MAE is reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home.” Yet, under the section Basic Coverage Criteria (A), the draft LCD the following: “the MRADLs to be considered in this and all other statements in this policy are toileting, feeding, dressing, grooming, and bathing performed in customary locations in the home.” The ITEM Coalition believes that this change in verbiage from the final NCD to the draft LCD represents an inconsistency between the two coverage determination policies. The language used in the draft LCD would have the impact of further restricting access to power mobility devices for individuals with disabilities by disallowing clinical consideration of other activities involving mobility during assessment.
Because the term “mobility related activities of daily living” was created
by CMS in the NCD for MAE, no definition of the term previously existed
in statute, regulations or manuals and there simply is no evidence in the
literature or in clinical practice that supports such a limited number
and range of ADL functions during mobility device assessment. The ITEM
Coalition believes that a significantly wider range of mobility related
activities should be considered as MRADLs as people with disabilities have
a daily need to accomplish functions other than toileting, feeding, dressing,
grooming and bathing. The five ADLs selected by the DMERCs to represent
the universe of functional abilities relevant for a Medicare beneficiary
to perform are highly restrictive and expose a mismatch between what DMERCs
will consider and the day-to-day needs of Medicare beneficiaries.
For example, a quadriplegic beneficiary with limited upper extremity movement
may never have the ability to cook for herself or bath herself independently
even with the use of a mobility device. However, with the appropriate mobility
device, the beneficiary may be able to move herself from the bedroom to
the computer room where she might be able to read an online newspaper or
participate in online classes. She may be able to travel to the kitchen
to answer the telephone, move to the bookcase to read a book, move to the
front door to pick up the mail, travel to the living room to watch television
or move to a patio to visit with a friend. None of these improvements in
function are currently recognized by the draft LCD and every one of them
is an example of the basic functional needs of most beneficiaries with
mobility impairments.
Mobility as an MRADL:
The ITEM Coalition strongly objects to the draft LCDs’ omission of “mobility”
itself in the document’s definition of mobility-related activity of daily
living. By definition, “mobility assistance equipment” and “power mobility
devices” are equipment used to aid in mobility. One’s capacity to improve
mobility, whether or not it improves one’s ability to perform some other
task, should be considered in the coverage determination process for mobility
devices.
The ITEM Coalition believes this omission is a major failing of the draft
LCD and is concerned that this omission will lead to denials for beneficiaries
with a legitimate need for wheelchairs and other mobility devices.
III. Other Concerns
The Role of the Caregiver in the Assessment Process:
The ITEM Coalition commends the DMERCs for taking into consideration the
role of the caregiver in the assessment process in the draft LCD. To be
sure, the ITEM Coalition agrees with the notion that a caregiver’s role
in assisting the beneficiary should help a beneficiary in receiving coverage
for a more appropriate device but should not operate against the beneficiary
in the assessment of need. However, this exception essentially creates
two separate coverage policies; one for those who have caregivers and one
for those who do not. Those who have caregivers are actually being assessed
appropriately on basic improvement in mobility. Yet, those beneficiaries
who do not employ caregivers’ services are being assessed inappropriately
on the completion of an MRADL as defined by this draft LCD. Therefore,
the ITEM Coalition encourages the DMERCs to clarify the role of the caregiver
so that the LCD may be applied consistently and clearly.
Under the Section Power Wheelchairs (K), the document states that “A power wheelchair is covered if……the patient has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing and able to safely operate the power wheelchair that is provided.” The ITEM Coalition believes that this is an appropriate standard to set as the caregiver’s role in assisting a beneficiary to safely utilize a power mobility device should be considered in granting coverage for the device.
In this spirit, the ITEM Coalition urges the DMERCs to clarify that capabilities of a caregiver may assist the beneficiary in obtaining the most appropriate and useful devices. For example, under the section Power Wheelchairs (J) the draft LCD would require that the patient have the “mental and physical capabilities to safely operate the power wheelchair that is provided….” ITEM Coalition members are concerned that this requirement might prevent some individuals with cognitive or mental impairments under caregiver supervision from receiving a needed mobility device. We encourage the DMERCs to clarify in this provision that beneficiaries with cognitive and physical disabilities, who can safely operate devices with or without the assistance of a caregiver, may be eligible for coverage.
Likewise, the ITEM Coalition urges the DMERCs to clarify that the assistance of a caregiver will not hinder the beneficiary’s ability to receive coverage for the most appropriate device. For example, if a beneficiary is able to operate a POV with the assistance of a caregiver, but they can independently operate a power wheelchair, the beneficiary should receive the power wheelchair. Under the section Power Operated Vehicles (D)(a), the LCD states that a patient is eligible if they are able to “independently transfer to and from a POV.” We recognize this to mean that a beneficiary will only receive coverage of a POV, rather than a power wheelchair, if transferring is possible without assistance of a caregiver or other individual. If this is indeed the intended meaning, the ITEM Coalition supports this provision but encourages greater clarification in this instance and other similar circumstances.
IV. Conclusion
The ITEM Coalition appreciates this opportunity to comment on the draft
LCDs for PMDs and encourages the DMERCs to seriously consider not only
these comments but the comments submitted by other consumer groups, clinician
groups and providers as they draft the final LCDs.
When the National Coverage Determination process for MAE began in December,
2004, the ITEM Coalition was optimistic that CMS and the DMERCs would create
clearer and more comprehensive coverage criteria in order to ensure that
beneficiaries receive the most appropriate mobility device for their needs.
However, upon the release of the final NCD and now the draft LCD, it has
become clear that CMS and the DMERCs are ultimately compromising beneficiary
access in an attempt to reduce costs in this benefit.
The existing draft LCD, as did the final NCD, simply fails to address the
real-life, medical and functional needs of Medicare beneficiaries. In our
opinion, this failure is primarily due to the restrictive interpretation
of the “in the home” criterion. This restriction runs counter to numerous
government initiatives such as the Ticket-to-Work program, the New Freedom
Initiative, and the Americans with Disabilities Act, which all aim to improve
community access for people with disabilities. As long as CMS and the DMERCs
continue to confine the assessment for mobility devices to in-home activities,
Medicare beneficiaries will not receive the appropriate technology they
deserve. Members of the ITEM Coalition urge the DMERCs to work with CMS
to remove these inappropriate and discriminatory restrictions.
Sincerely,
The ITEM Coalition Steering Committee
Kim Ruff-Wilbert
United Spinal Association
Peter W. Thomas
Consortium for Citizens with Disabilities Health Task Force
Mark Richert
American Foundation for the Blind
Lee Page
Paralyzed Veterans of America
Eva DuGoff
Medicare Rights Center
Attachments: ITEM Coalition Member List
|
