As the Rolling Stones' song says, you can't always get what you want….
And, in today's wheelchair funding climate, that line is truer than ever, with many users "downcoded" to lower-end mobility products than they wish. As an example, current Medicare/Medicaid power wheelchair allowables dictate the "least costly alternative," where one may want the top-of-the-line 8mph power wheelchair, but the allowable will only fund a more conservative 5mph model. Indeed, you can't always get what you want.
Yet, Medicare policy has a provision where you may still obtain the mobility product you wish - that is, if you can afford to pay for the price difference yourself. While Medicare will only fund the least costly alternative for one's mobility - as in the example of a Group 3 instead of a Group 4 powerchair - policy allows the beneficiary to pay the difference for the upgraded product, called the Advanced Beneficiary Notice (ABN).
The way the ABN process works is that if a beneficiary wishes a coded item that's above what's approved for them by Medicare - again, using a Group 3 to Group 4 powerchair as an example - the beneficiary can sign the ABN and pay the difference to receive the more costly product. For instance, if Medicare approved a Group 3 powerchair for you at $5,900, but you wish the Group 4 at $6,900, then you have the right to use the ABN to pay the $1,000 difference out-of-pocket yourself, and receive the more costly product.
An ABN is a standard part of the Medicare process, so providers are trained in the protocol, which consists of a form noting the ABN item, its cost, and the beneficiary's signed agreement to pay the cost. It's important to note that the ABN is only used toward coded items - that is, such upgrades as Group to Group or power seating upcharges are addressed with an ABN, but unrecognized options like a cup holder or safety flag would not require an ABN (the provider would charge the beneficiary separately from the Medicare process).
Almost all providers require payment at the signing of the ABN, so the beneficiary must be prepared to pay for the ABN item wished when the mobility product is ordered. Certainly, the ABN creates a catch-22 for many beneficiaries, where they have the right to pay for upgrades, but lack the financial resources to do so. This is a reality for many, and based on the ABN policy, there's no financial distinction from one beneficiary to the next - if you can afford the ABN item, you can receive it, and if you can't afford it, then you'll only receive what's covered by Medicare. (For privately insured beneficiaries, it's important to check with the insurer, as some have an ABN-type process, while others do not.) Still, there's empowerment in paying a portion toward your mobility, having some control over your own checkbook to obtain what you want in a mobility product.
While not all beneficiaries have the financial means to use the ABN, all do have the right - and there's some equity to the process where those willing and able to invest in their mobility have the right to do so. The next time you're funding a new mobility product, and wish for a bit of an upgrade, consider using the ABN process, where the complete Rolling Stones' chorus line proves true: You can't always get what you want, but if you try, sometimes you might find you get what you need.