Washington, DC- February 4, 2005- United Spinal Association, a national disability rights organization, condemns the Center for Medicare and Medicaid Services (CMS) for its continued refusal to address Medicare’s restrictive “in-the-home” policy. This policy continues to deny people with disabilities access to appropriate and necessary power wheelchairs or scooters. CMS released its new Medicare draft coverage criteria for power wheelchair and scooters late yesterday afternoon and again failed to address this “in-the-home” restriction.

“In-the-home” 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, it is interpreted by CMS to restrict coverage only to wheelchair and other mobility devices that are necessary within the beneficiary’s home. “Not only does this restriction severely impede on the health and independence of people with disabilities by confining them to the four walls of their homes,” stated Kim Ruff-Wilbert, policy analyst for United Spinal, “But it does not take into account the need for beneficiaries to access their communities.”

The Association also believes that the “in-the-home” restriction runs counter to the Bush Administration’s goals under the New Freedom Initiative, which is to help people with disabilities live independent and productive lives. “How can you encourage return to work and promote independent living, but then refuse to provide the appropriate technology necessary for carrying out these activities? It is counter productive and hypocritical.” Ruff-Wilbert continued.

United Spinal now intends to seek legislation that would remove “in-the-home” from the law. “If CMS wants to continue using this interpretation that traps people with disabilities inside their homes, then we will strive to have the language removed via legislation.” said Gerard M. Kelly, Executive Director of United Spinal. “CMS’s continued refusal to address this issue is immoral, and we will now ask Congress to intervene.”

United Spinal Association is dedicated to enhancing the quality of life for individuals with spinal cord injury or spinal cord disease by assuring quality health care, promoting research, and advocating for civil rights and independence by educating the public about these issues and enlisting their help to achieve these fundamental goals. It is a Steering Committee member of the ITEM Coalition, whose 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.

Washington, DC – May 6, 2005 – The United Spinal Association, a national disability rights organization, continues to condemn the Center for Medicare and Medicaid Services (CMS) for the agency’s ongoing refusal to address Medicare’s restrictive “in-the-home” policy.  CMS released its final National Coverage Determination (NCD) decision memo late yesterday afternoon and, yet again, failed to address the “in-the-home” restriction.  The Association believes this policy continues to deny people with disabilities access to appropriate and necessary power wheelchairs or scooters.

“This is a huge missed opportunity by CMS.  Their refusal to take action will continue to deny Americans with disabilities their freedom as the ‘in-the-home’ restriction imprisons Medicare beneficiaries in their homes by refusing access to the appropriate and necessary power wheelchairs and scooters for independent living,” said Kim Ruff-Wilbert, a Policy Analyst with United Spinal. “Furthermore, the newly established clinical guidelines are near meaningless when they are implemented under the ‘in-the-home’ policy because equipment will still be denied at the most basic level.”  

“In-the-home” 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, CMS chooses to interpret it as a restriction in coverage to only mobility devices that are considered reasonable and necessary within the beneficiary’s home.  Despite CMS’ initiation of the lengthy NCD process to rewrite the coverage guidelines for mobility devices, beneficiaries who may not need equipment to fully function at home but need such devices to access their communities, work, school, physicians’ offices, pharmacies, or places of worship, will continue to be denied coverage for a wheelchair by Medicare under this restriction.

United Spinal now intends to seek legislation that would remove “in-the-home” from the law. “If CMS wants to continue using this interpretation that traps people with disabilities inside their homes, then we will strive to have the language removed via legislation.” said Gerard M. Kelly, Executive Director of United Spinal. “CMS’ continued refusal to address this issue is immoral, and we will now ask Congress to intervene.” United Spinal Association is a Steering Committee member of the ITEM Coalition, whose 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.

Center for Medicare and Medicaid Services

From: United Spinal Association

Date: March 7, 2005

United Spinal Association, a national disability rights organization dedicated to enhancing the quality of life for individuals with spinal cord injury or spinal cord disease by assuring quality health care, promoting research, and advocating for civil rights and independence, submits the following comments on the draft decision memorandum under the National Coverage Determination (NCD) process for mobility assistive equipment (CAG-00274N) released by the Center for Medicare and Medicaid Services (CMS) on February 3, 2005.

CMS Must Address “In-the-Home”
United Spinal Association continues to express our significant dismay with CMS as you continue to perpetuate the archaic and discriminatory “in-the-home” restriction. You neglect, yet again, to modify “in-the-home” under this draft NCD. The “in-the-home” policy continues to deny people with disabilities access to the appropriate and necessary wheeled mobility for living independent lives.

As you know, the “in-the-home” language was originally meant to define durable medical equipment as devices provided outside of an institution such as a hospital or skilled nursing facility and, therefore, warranted separate reimbursement under Medicare Part B. Instead, you choose to continue interpreting this language as restricting coverage of wheelchairs and other mobility devices that are only necessary for use in the patient’s home.

United Spinal is encouraged by your intent to delete the “bed or chair confined” criterion currently used. However, this change will account for very little progress unless CMS also addresses the most biased and inequitable aspect of the Medicare wheelchair benefit: the “in-the-patient’s-home” restriction. As we and countless others continue to assert, the “in-the home” restriction severely impedes on the health and independence of people with disabilities, as it confines them to the four walls of their homes and does not take into account the need for beneficiaries to access their communities, physician’s office, pharmacy, grocery store, bank or place of worship. Your interpretation prevents individuals from receiving the appropriate technology necessary to live as integrated and productive members of American communities.

While moving to a functional based criteria is generally a laudable improvement, any functional assessment of a patient will be incomplete if that assessment is limited to the beneficiaries’ functional abilities in their homes. This restriction will continue to inhibit community integration and limit the independence and freedom of people with disabilities. Unless your new coverage guidelines reflect the functional assessment of a beneficiary’s needs outside of the home, any new functional clinical guidelines CMS may choose to adopt are irrelevant. Access will continue to be denied at the primary level, and people with disabilities will be prisoners in their homes.

In addition, the “in-the-home” restriction places clinicians, doctors and providers in extremely difficult moral and ethical situations. “In-the-home” affects a clinicians’ ability to make sound clinical decisions often preventing them from prescribing the most appropriate device. These actions place beneficiaries at high risk for additional injuries that will lead to increased costs in Medicare.

United Spinal Association recommends CMS modify the “in-the-home” restriction.

The Appropriate Mechanism?
CMS fails to acknowledge and appropriately address the “in-the-home” restriction in the draft NCD. You state that “an NCD would not be the appropriate mechanism to change this rule,” but fail to offer any information as to what is the appropriate mechanism. This restrictive interpretation negatively impacts on the ability of CMS to draft a coherent and effective NCD based on functional criteria. In essence, as long as this NCD process ignores “in-the-home”, it is nothing more than an exercise in futility.

While CMS has alluded to the need for legislation in order to address “in-the-home”, United Spinal firmly believes that you have the authority to address this issue through the formal rule-making process. In fact, Thomas Hoyer, Director of the Office of Chronic Care and Insurance Policy, Bureau of Policy Development for the Health Care Financing Administration (CMS) echoed this belief in a January 3, 1995 letter stating that “”If we (CMS) determine that the requirement of home needs further clarification, we will issue regulations to achieve that purpose.”

Furthermore, throughout this process you have never taken a position as to whether the “in-the-home” restriction hinders your ability to provide appropriate and necessary power wheelchairs and scooters giving people with disabilities their independence, freedom and ability for full community integration.

United Spinal Association recommends CMS inform the public of how it intends to address this archaic and inequitable policy. We also seek clarification from CMS of it authority (or lack there of) to interpret “in-the-patient’s-home” as used in the Medicare statute. Finally, we urge CMS to state its position as to whether believes this language impedes its ability to develop effective functional and clinical assessment guidelines and to provide appropriate mobility assistive devices.

Mobility itself is an Activity of Daily Living

United Spinal supports deleting the “bed or chair confined” criterion. However, we do not support tying medical necessity to a beneficiary’s ability to complete mobility related activities of daily living (MRADL) as long as these MRADLs take place exclusively in the confines of the beneficiary’s home.

CMS defines mobility-related activities of daily living (MRADL) as feeding, bathing, grooming, toileting and dressing. All MRADLs are activities confined to the home. By requiring that a mobility device assist a beneficiary in completing a MRADL, you fail to account for the beneficiary’s need to complete activities other than eating, bathing, grooming, dressing and toileting in order to be healthy, functional and independent.

Mobility itself should be considered an activity of daily living. The ability to move from point A to point B is equally a functional improvement as completing the task of brushing your teeth, and it should be viewed as such. “Improvement in mobility” should be a sufficient criterion for coverage of a power wheelchair, as the purpose of a mobility device is to increase mobility. By requiring that a patient complete a specific MRADL, you fail to account for the needs of beneficiaries with conditions that might prevent them from completing an ADL such as a quadriplegic or an individual with cognitive impairments. In each of these cases, mobility is certainly an improvement and increase in function.

United Spinal Association recommends CMS incorporate ambulation mobility into the agency’s definition of mobility related activities of daily living as mobility itself is an increase in function.

Clarify Care Givers Role
United Spinal expresses concern over the beneficiary/care giver relationship as set forth in the draft NCD. This relationship could end up precluding beneficiaries, who are currently eligible for power wheelchairs and scooter, given your definition of ambulation, from qualifying.

United Spinal Association requests CMS clarify your position on the role of care givers as they related to helping a beneficiary meet MRADLs.

Conclusion
CMS’ continued refusal to address the “in-the-home” restriction in the draft NCD represents an enormous missed opportunity. Despite demands for greater independence and community integration 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, you appear intent on maintaining a rule that keeps people with disabilities prisoners in their homes. It is counter productive and hypocritical to promote independent living and encourage return to work, but then determine that the appropriate technology necessary for carrying out these activities is unavailable due to the “in the home” restriction.

United Spinal asks that you please take the time to consider all comments submitted on this draft NCD. Evaluating public comment is a critical and integral part in preserving the transparency intended in the national coverage determination process. Thank you.

Sincerely,

Gerard Kelly
Executive Director
United Spinal Association

Washington, D.C. - February 16, 2005 — At a briefing hosted by Congressman James Langevin (D-RI) and the Independence Through Enhancement of Medicare and Medicaid (ITEM) Coalition yesterday, United Spinal Association and other disability advocates spoke out against the negative impact of the “in the home” policy, which restricts Medicare coverage to power wheelchairs and scooters that are considered medically necessary only for use inside the beneficiary’s home. The briefing was held during the National Coalition for Assistive and Rehab Technology (NCART) Fair and Congressional Fly-In in Washington, DC, on February14^th and 15^th.  

• Remove the "in-the-home" restriction, which only creates administrative burdens on DME suppliers and clinicians, and limits beneficiary access to wheeled mobility;
• Create a mechanism for processing physician referrals and assure timely access to the clinical evaluation process;
• Develop a comprehensive and definitive National policy that indicates eligibility criteria based on function and the specific services provided;
• Establish a detailed service delivery plan;
• Develop strict guidance delineating authority for determining who is allowed to conduct clinical evaluations;
• Establish a funding source and set up a fee schedule for clinical evaluation services.
• Establish a prior authorization procedure

United Spinal is hopeful that the efforts and resources of CMS and IWWG, while focused on developing new coverage guidelines based on proven clinical guidance, will also focus on the “in-the-home” restriction. Only CMS has the authority to free beneficiaries from the confines of their beds and their homes. United Spinal strongly urges CMS to adopt coverage guidelines that focus on a functional based clinical evaluation devoid of the “in-the-home” restriction.

Gerard Kelly
Executive Director
United Spinal Association

December 22, 2004

Washington, DC – The United Spinal Association announced its grave concern with the continued refusal by the Center for Medicare and Medicaid Services (CMS) to address Medicare’s “in-the-home” restriction.  On December 15^th, CMS released recommendations from the Interagency Wheelchair Work Group (IWWG) for new Medicare wheelchair coverage guidelines based on functional assessment; however, this action will not alter the “in the home” restriction faced by many Medicare clients, that if they are able to leave their home, they can never qualify for a power wheelchair.

CMS’ December 15^th action triggers the current 30-day comment period; up to an additional six months for development of a draft decision memorandum; and another comment period following the release of that memorandum.  This process is a more formal, time-limited procedure in which CMS will review Medicare wheelchair coverage policy, but it also signals an additional delay in resolving the “in the home” restriction. 

“We were awaiting the release of actual draft guidance from CMS, but instead we seem to be at the beginning of this process over again,” stated Kim Ruff-Wilbert, a policy analyst for United Spinal.  “We intend to push hard for CMS to finally address the ‘in-the-home’ restriction.  In the meantime, we will continue our fight to preserve beneficiaries’ access to their wheelchairs.”

“The ’in the home’ restriction severely impedes the health and independence of United Spinal’s members and all individuals with disabilities, as it essentially confines people to the four walls of their homes and does not take into account the need for people to access their physician’s office, pharmacy, grocery store, bank or place of worship,” stated Jeremy Chwat, Director of Policy for United Spinal.  “Unless the new criteria include a functional assessment of the beneficiary’s needs outside of the home, the process will continue to deny necessary power wheelchairs to Medicare beneficiaries.”

The “in the home” restriction (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) has been interpreted by CMS to limit coverage only to wheelchair and other mobility devices that are reasonable and necessary within the beneficiary’s home.

United Spinal Association is a Steering Committee member of the ITEM Coalition, whose 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.  United Spinal Association is dedicated to enhancing the quality of life for individuals with spinal cord injury or disease by assuring quality health care, promoting research, advocating for civil rights and independence, educating the public about these issues and enlisting its help to achieve these fundamental goals.

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