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APRIL 2005

The Effects of Medicare’s “In-the-Home” Restriction on Beneficiaries

By Paul Tobin

As a person living with a spinal cord injury, and the Deputy Executive Director of the United Spinal Association, I can attest that wheelchairs play an integral role in assisting millions of disabled Americans living independently everyday.  United Spinal is a national disability advocacy organization dedicated to enhancing the quality of life for individuals with spinal cord injury and spinal cord disease by assuring quality health care, promoting research, and advocating for civil rights and independence.  We understand the important role that wheelchairs play in empowering Americans with disabilities, and United Spinal is committed to repealing Medicare’s unfair coverage and administrative policies relating to power wheelchairs and scooters. The most discriminatory and archaic Medicare policy is the “in-the-patient’s-home” restriction, which severely impedes on the health and independence of people with disabilities, as it fails to take into account the need for people to access their physician’s office, pharmacy, grocery store, bank or place of worship, by confining them to the four walls of their homes.

The Medicare “in-the-home” language was originally meant to define durable medical equipment as devices that were provided outside of an institution such as a hospital or skilled nursing facility, and therefore, warranted separate reimbursement under Medicare Part B. Instead, the Center for Medicare and Medicaid Services (CMS) chooses to interpret “in-the-home” as a restriction in coverage to power wheelchairs and scooters that are considered reasonable and necessary only in the beneficiary’s home. In other words, beneficiaries who need a wheelchair to function outside of their home are denied access to the appropriate and necessary technology essential for achieving independence, freedom and community integration. 

In recent months, CMS indicated a shift in coverage policy from the current “bed or chair confined” criterion to a functional based criteria. While this is generally a laudable improvement, any functional assessment of a patient will be incomplete if that assessment is limited to a beneficiary’s functions inside of their home. Unless new coverage guidelines reflect a beneficiary’s functional needs outside of the home, any new coverage guidelines CMS may choose to adopt are irrelevant. Access will continue to be denied at the primary level, and people with disabilities will continue as prisoners in their homes.

CMS’ continued refusal to address the “in-the-home” restriction represents an enormous missed opportunity. Despite demands for greater independence from beneficiaries, advocates, clinicians, providers and even the Administration, by way of the New Freedom Initiative, Federal programs such as Ticket to Work and the U.S. Supreme Court Olmsted decision, CMS appears intent on maintaining a rule that keeps people with disabilities confined to their homes. It is counterproductive and hypocritical to promote independent living and encourage return to work, but then deny people the appropriate technology necessary for carrying out these activities under the “in-the-home” restriction.#

Paul J. Tobin, Deputy Executive Director of United Spinal Association, holds a degree in Civil Engineering and earned a  commission in the United States Navy in 1991. Duty stations included the Naval Training Center in Orlando, Florida, and the Naval Air Warfare Center in Lakehurst, New Jersey, where he served as Assistant Resident Officer In Charge of Construction. Tobin sustained a spinal cord injury in August 1993 and, after rehabilitation, he joined United Spinal’s Board of Directors, serving from 1995 to 1996. Prior to becoming Deputy Executive Director, Tobin served as the organization’s Hospital Services Officer, Director of Special Projects, Group Director of Benefit Services and Associate Executive Director of Benefit Services.

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