Key Takeaways:

  • A prescription from your doctor starts the process by confirming you medically need a wheelchair, while prior authorization is your insurance company’s approval that the equipment meets their coverage requirements.
  • Manual wheelchairs often only need a prescription, but power or custom models usually require prior authorization and additional medical documentation.
  • Your doctor and equipment supplier will handle most of the paperwork, but it also never hurts to stay in touch with them to help prevent delays.

Getting a wheelchair through insurance or Medi-Cal isn’t always the most straightforward process. Between prescriptions, paperwork, and prior authorization requirements, it can feel like there’s a lot to keep track of.

This guide breaks down what each step means, how they work together, and what you need to know to make sure your wheelchair is properly covered.

Prior Authorization vs. Prescription: What’s the Difference?

Prescription

A prescription is a doctor’s written order stating that you need a wheelchair for medical reasons. Without this documentation, insurance companies, including Medi-Cal (California’s version of Medicare), won’t consider paying for the device. 

Prior Authorization

Prior authorization is a review process by your insurance company. Before the wheelchair can be provided or paid for, the insurer must confirm the equipment is medically necessary and meets their coverage criteria. In other words, the prescription starts the process, and prior authorization gives it the green light.

For example, your doctor might prescribe a power wheelchair, but your insurance company may require prior authorization to verify that a power model is appropriate for your needs before they agree to cover it.

What Is Prior Authorization and When Is It Needed?

As mentioned above, prior authorization, sometimes called “pre-approval,” is essentially permission from your insurance company to proceed with a service or piece of medical equipment. It’s common for treatments or devices that are expensive, long-term, or require specialized fitting.

Not all wheelchairs require prior authorization; however, if you need a more advanced model, such as a motorized or custom-fitted chair, your insurer or Medi-Cal will likely request additional documentation before approving payment.

The purpose of this step is to protect both you and the insurer. However, in some cases, it can take a good amount of time, especially if more information is requested.

Who Is Responsible for Getting Prior Authorization?

The responsibility is usually shared between your doctor and your medical equipment supplier. Your doctor is responsible for providing detailed medical records to prove necessity, while your supplier or mobility provider typically submits the prior authorization request to your insurance company or Medi-Cal contractor; this will include the doctor’s notes, prescription, and a quote for the equipment being requested.

Once the paperwork is submitted, the insurance company reviews the information. If your request is approved, you’ll be notified that the chair can be delivered. If it’s denied, your provider and doctor can appeal by sending more documentation.

While you don’t usually have to file anything yourself, it can help to stay in touch with your doctor and supplier to make sure nothing gets delayed.

Do You Need a Prescription for a Wheelchair?

Yes, a prescription is always required if you plan to have your wheelchair covered by insurance or Medi-Cal. The prescription must come from your treating physician after an in-person evaluation. It should specify the type of wheelchair you need and include details about your medical condition, mobility limitations, and how the wheelchair will help you move safely in your home.

Without this documentation, insurance companies can’t process your claim, and you’ll be responsible for the full cost. If you’re paying out of pocket, you don’t technically need a prescription, but having one can still be helpful if you decide you want to be reimbursed in the future.

Does Medi-Cal Cover Wheelchairs?

Yes, Medi-Cal does cover wheelchairs when certain conditions are met. The equipment must be considered medically necessary, prescribed by a doctor, and provided through a Medi-Cal-approved supplier.

Medi-Cal generally covers three categories of mobility devices: manual wheelchairs, power wheelchairs, and scooters. Manual models typically require only a prescription, while most power wheelchairs and scooters also need prior authorization before Medi-Cal will approve payment.

How to Get a Wheelchair Covered by Medi-Cal or Insurance

Simply put, the process usually looks like this:

  1. Your doctor evaluates your condition and determines if you need a wheelchair.
  2. They write a prescription and provide supporting medical documentation.
  3. Your supplier submits the paperwork to Medi-Cal for prior authorization if it’s required.
  4. Medi-Cal reviews and issues a decision, usually within about 10 business days.

Once approved, you can review your wheelchair through the supplier, and Medi-Cal will cover its share of the cost (typically 80% after your deductible). If coverage is denied, you have the right to appeal the decision or resubmit with additional information.

Have Insurance Questions? We’re Here to Answer Them

The topic of insurance coverage can be confusing and in of itself. Fortunately, at Freedom Mobility Center, we’re here to help you handle the process with ease. Our team will work directly with your doctor and insurance provider to make sure all the correct paperwork is submitted.

Whether you’re ready to look at wheelchairs or have further questions about the approval process, contact us today to set up a consultation or see if you qualify for a power wheelchair.