Medicare coverage of class III medical mobility devices

(a)

Covered benefit

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— (1)in subparagraph (Z), by striking and at the end; (2)in subparagraph (AA), by inserting and at the end; and (3)by adding at the end the following new subparagraph:

(BB)class III medical mobility devices (as defined in subsection (ccc)(1)) furnished to a class III medical mobility-device eligible individual (as defined in subsection (ccc)(2));

(b)

Definitions

Section 1861 of such Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

(ccc)

Class III medical mobility device; class III medical mobility-device eligible individual

(1)The term ‘class III medical mobility device’ means a medical mobility device that has been approved as a class III medical device pursuant to a premarket approval application under the Federal Food, Drug, and Cosmetic Act and that— (A)is able, among other functions— (i)to ascend and descend stairs using a climbing and descending function; (ii)to traverse different terrain and various obstacles (including uneven terrain, curbs of 5 inches in height, grass, gravel and other soft surfaces) using a 4-wheel drive function; and (iii)to provide mobility in a seated position at an elevated height using a balance function; (B)has been prescribed for a class III medical mobility-device eligible individual (as defined in paragraph (2)) by the individual’s treating physician (as defined in subsection (r)(1)) for an approved indication of the class III medical mobility device; and (C)is only dispensed after an assessment of the class III medical mobility-device eligible individual has been completed by a health care professional specified in paragraph (3) who has successfully completed training in making such assessments under standards specified by the Secretary in consultation with representatives of appropriate industry and medical organizations. (2)The term class III medical mobility-device eligible individual means, with respect to a class III medical mobility device, an individual who, at the time the prescription for the device is written, meets each of the following requirements: (A)The individual suffers from a functional limitation of mobility that hinders the individual’s ability to perform mobility-related activities of daily living. (B)The individual demonstrates sufficient cognitive and physical ability for the proper and safe operation of the device (such as sufficient use of one upper extremity and the ability to dial a push button telephone or operate a hand operated joystick) under such medical standards as the Secretary may specify. (C)The individual meets drivers licensing criteria established in 1996 by the Epilepsy Foundation of America. (D)The individual does not require mechanical ventilation. (E)The individual is not a resident of an institution that meets the requirements of subsection (e)(1) or section 1819(a)(1). (F)The individual has completed a comprehensive training program (that meets standards developed by the Secretary in consultation with appropriate industry representatives) on the safe operation of the class III medical mobility device and its functions. (3)A health care professional specified in this paragraph is any of the following: (A)A physician (as defined in subsection (r)(1)). (B)A physician assistant. (C)A nurse practitioner. (D)A qualified physical therapist. (E)A qualified occupational therapist.

(c)

Conforming amendments

(1)

Provision of class iii medical mobility device only to class III medical mobility-device eligible individuals; medical necessity

Section 1862 of such Act (42 U.S.C. 1395y) is amended— (A)in subsection (a)(1)— (i)in subparagraph (M), by striking and at the end; (ii)in subparagraph (N), by striking the semicolon at the end and inserting , and; and (iii)by inserting after subparagraph (N) the following new subparagraph:

(O)in the case of a class III medical mobility device (as defined in paragraph (1) of section 1861(ccc)), which is furnished other than to a class III medical mobility-device eligible individual (as defined in paragraph (2) of such section);

; and

(B)by adding at the end the following new subsection:

(n)

Clarification of coverage of and payment for all functions of class iii medical mobility devices

In the case of a class III medical mobility device (as defined in section 1861(ccc)(1)) furnished to a class III medical mobility-device eligible individual, each function of such device, including the functions described in subparagraph (A) of such section, are deemed for purposes of subsection (a)(1), to be reasonable and necessary for the treatment of an illness or injury or to improve the functioning of a malformed body member.

(2)

Payment in connection with covered items; purchase agreement option; maintenance

Section 1834(a) of such Act (42 U.S.C. 1395m(a)) is amended— (A)in paragraph (1)(B)(ii), by inserting and (22) in the case of a class III medical mobility device, after (7); (B)in paragraph (13), by inserting before the period at the end the following: , and also includes a class III medical mobility device (as defined in section 1861(ccc)(1)); and (C)by adding at the end the following new paragraph:

(22)

Payment for class III medical mobility devices

(A)

In general

Subject to the succeeding provisions of this paragraph, in the case of a class III medical mobility device (as defined in section 1861(ccc)(1)), the provisions of paragraph (7) (including the option for a purchase agreement under subparagraph (A)(iii) of such paragraph) shall apply to such device under this paragraph in the same manner as those provisions apply to a covered item under paragraph (7). (B)

Payment for all functions of class iii medical mobility devices

In the case of a class III medical mobility device, payment under this paragraph for such device shall be made taking into account all functions of such device, consistent with section 1862(n). (C)

Limitation on aggregate number of devices covered during 2007 through 2011

With respect to class III medical mobility devices furnished during each of 2007 through 2011, payment shall only be made under this subsection for 1,000 such devices furnished in each such year. The limitation on payment under the preceding sentence for class III medical mobility devices shall not apply with respect to any year beginning after 2011.

(3)

Requirement for face-to-face encounter with a physician and for written prescription

Clause (iv) of section 1834(a)(1)(E) of such Act (42 U.S.C. 1395m(a)(1)(E)) is amended— (A)by adding at the end the following: In the case of a covered item consisting of a class III medical mobility device (as defined in paragraph (1) of section 1861(ccc)) for a class III medical mobility-device eligible individual (as defined in paragraph (2) of such section), payment may not be made for such item unless a physician (as so defined) has conducted a face-to-face examination and written a prescription for the item, and after an assessment of such individual has been completed by a health care professional specified in paragraph (3) of such section.; and (B)in the heading, by inserting

and class III medical mobility devices

after

wheelchairs

. (d)

Effective date

The amendments made by this section shall apply to items and services furnished on or after January 1, 2007.