A Storm Destroyed His 3-Year-Old Wheelchair. Medicare’s 5-Year Rule May Not Apply, and He Could Owe 20% for a New One

Imagine a retiree whose wheelchair is wrecked beyond repair when a storm rips through his neighborhood. Original Medicare paid for the chair three years ago. He remembers hearing that Medicare won’t replace equipment before five years. So he starts pricing a new chair out of pocket, or plans to get by without one until the time runs out.

He has the rule backward for his situation. Medicare paid for the chair and a storm destroyed it, so he likely qualifies for a replacement now, and what he does over the next few weeks decides how smoothly that goes.

Five Years Covers Ordinary Wear Only

Medicare gives durable medical equipment a reasonable useful lifetime, generally at least five years. That time controls replacement for wear: a frame that cracks from daily use, or a motor that fails after years of service. CGS Administrators, a contractor that processes Medicare equipment claims, explains this in its guidance. As one of Medicare’s equipment claims contractors, it says Medicare will not pay to replace an item for irreparable wear while that lifetime is still running.

Loss, theft and permanent damage from a specific accident or natural disaster fall under a separate rule. Those events can justify replacement before the five-year mark. Medicare.gov addresses getting care in a disaster or emergency. It says that when Original Medicare already paid for damaged or lost equipment, Medicare will in most cases cover the cost to repair or replace it, as long as the beneficiary gets it from a Medicare-approved supplier. A chair destroyed at year three fits that category.

The same exception can apply to walkers, hospital beds and other Medicare-covered equipment. If yours is lost, stolen or damaged beyond repair, ask about replacement before paying out of pocket, even if five years haven’t passed.

He Has to Prove What Happened

Medicare allows equipment replacement after loss, theft or damage beyond repair, but the supplier needs documentation to support the claim. He should be ready to show what happened to his chair. Photos, an insurance claim, a police or fire report, or other evidence tying the damage to the storm can help.

He generally needs a new order from his treating practitioner, even if his condition hasn’t changed. The supplier should check whether any disaster waiver changes that requirement. A replacement usually means the same chair or a similar one. If he now needs a different type, his medical records must show why. Certain power wheelchairs also require Medicare’s approval before delivery.

Use a Medicare-Approved Supplier

Choosing a Medicare-enrolled supplier is the first step toward getting the replacement covered. Medicare.gov’s durable medical equipment coverage page says Medicare pays only for items from suppliers enrolled in Medicare. It also tells beneficiaries to ask whether a supplier accepts assignment before getting equipment, since with assignment, Medicare pays its share and he pays his share of the Medicare-approved amount, with no surprise markup.

With a supplier that accepts assignment, he pays 20% of the Medicare-approved amount after meeting his Part B deductible.

Paperwork takes time, and he needs to get around in the meantime. Medicare usually covers a temporary wheelchair rental during repairs. His chair needs replacing, so he shouldn’t assume that rule covers the wait. On the first call, he should ask about a loaner or rental chair and who would pay for it.

Medicare Advantage members follow a different path. Medicare.gov says plans handle disaster replacement directly, so the first call goes to the number on the plan card. Medicare’s equipment booklet notes that each plan sets its own suppliers and costs. If a plan denies a needed item, the member can appeal and get an independent review.

Start the Claim Before the Evidence Fades

The longer he waits, the harder it gets to tie the damage to the storm, and every week of delay is another week without reliable mobility. He should report the loss to his supplier quickly and build a file now:

• Photos of the damaged chair and the storm damage around it
• Insurance claim paperwork or adjuster reports
• The chair’s make, model and serial number, often on a frame label or the original delivery invoice
• The names of his treating practitioner and the original supplier

He doesn’t need to wait for an official disaster declaration to ask for a replacement. A declaration may bring temporary changes to Medicare’s usual requirements, so he should ask the supplier whether any apply. If the supplier turns him away because the chair is less than five years old, he can ask for the reason in writing and call 1-800-MEDICARE (1-800-633-4227) for help.

The five-year clock applies to ordinary wear. When a storm destroys his chair at year three, the reason for replacement matters more than its age. His next step is a call to a Medicare-enrolled supplier this week, with his photos, insurance paperwork and a request for a rental chair ready.

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