Existing law establishes the Medi-Cal program, which is administered by the State Department of Health Care Services and under which qualified low-income individuals receive health care services. The Medi-Cal program is, in part, governed and funded by federal Medicaid program provisions.

Existing law, subject to any necessary federal approvals, sets forth various Medi-Cal provisions relating to complex rehabilitation technology (CRT), which is a form of durable medical equipment, including, but not limited to, complex rehabilitation manual and power wheelchairs. Existing law requires a CRT provider to comply with certain standards, including with regard to CRT repairs. Existing law authorizes the department to adopt any utilization controls for CRT, as appropriate.

This bill would prohibit the department from requiring prior authorization for the repair of a CRT-powered wheelchair if the cost of the repair does not exceed $1,250. Under the bill, a treatment authorization request for repair or replacement of a CRT-powered wheelchair would not require an individual prescription or documentation of medical necessity from the treating practitioner if the CRT-powered wheelchair has already been approved for use by the patient.

For repair of a CRT-powered wheelchair, the bill would require the supplier to document and maintain records of the items being repaired, the reason for the repair, and the labor details, as specified, with the information being subject to a postpayment audit by the department. The bill would set forth other recording requirements for the supplier.

Date of Hearing: April 30, 2025

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Buffy Wicks, Chair

ABPCA Bill Id:AB 517

Author:(Krell) – As Introduced Ver:February 10, 2025

Urgency: No State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill prohibits the Department of Health Care Services (DHCS) from requiring prior authorization under Medi-Cal for the repair of a complex rehabilitation technology (CRT)-powered wheelchair if the cost of the repair does not exceed $1,250.

This bill also:

1. Prohibits DHCS from requiring, as part of a treatment authorization request (TAR) process, a prescription or documentation of medical necessity from the treating practitioner requesting the repair or replacement, if the CRT-powered wheelchair has already been approved for use by the patient.
2. For Medi-Cal to cover repair of a CRT-powered wheelchair, requires a supplier to document and maintain records of the items being repaired, the reason for the repair, and the labor details associated with the repair. Requires the supplier to make this documentation available upon request by DHCS, and authorizes DHCS to conduct a post-payment audit.
3. Requires a supplier to ensure the equipment and related repair details are recorded in a manner that demonstrates proof of continuous medical need, and, once the CRT powered wheelchair is recorded, requires any subsequent repairs to follow the process outlined in item 2, above.

FISCAL EFFECT:

Costs to DHCS of an unknown amount, potentially over $150,000 in the first year of implementation, to adopt new policies and communicate new rules to Medi-Cal providers, beneficiaries, and suppliers (General Fund, federal funds).

COMMENTS:

Purpose. This bill is sponsored by the California Foundation for Independent Living Centers. According to the author:

AB 517 aims to eliminate barriers to timely repairs for Californians who depend on powered wheelchairs for their independence. By removing the requirement for prior authorization for repairs under $1,250 and simplifying documentation, this bill ensures that individuals with disabilities will have quicker access to the repairs they need to stay mobile and independent. This bill addresses critical delays in the repair process, which currently place patients at risk of being without their essential devices for weeks at a time. In addition, it allows [DHCS] to conduct post payment audits to ensure compliance and detect any potential fraud. AB 517 will help improve the quality of life for individuals who rely on complex rehabilitation technology, allowing them to regain their mobility and dignity without unnecessary red tape.

Medi-Cal Coverage of CRT and Prior Authorization. Medi-Cal reimburses providers for medically necessary CRT. DHCS requires prior authorization through a process called a TAR, which is a form that must be reviewed and approved by DHCS before it authorizes payment for services or equipment. After submitting a TAR, a provider receives an electronic “Adjudication Response” from DHCS informing them a service is approved, denied, or modified. DHCS also requires a TAR for repairs of CRT, which is the subject addressed by this bill.

According to the author, sponsor, and industry stakeholders, the TAR process for repairs creates on average a 21-day delay in service and repairs. The TAR process for repairs is complicated by the requirement to demonstrate medical necessity, requiring input from both the individual’s medical provider and the CRT provider who actually performs the repair. Stakeholders say medical providers often do not have direct knowledge of the mechanical functioning of the equipment they have deemed medically necessary for a patient, and therefore the provider’s involvement adds limited value and significant administrative burden and delay. According to this bill’s sponsor, when someone with a severe physical disability and impaired mobility experiences a malfunction with their wheelchair or other mobility device, it is often an urgent or even emergency situation, as the individual may be literally immobilized and unable to perform activities of daily living.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 8, 2025

ASSEMBLY COMMITTEE ON HEALTH

Mia Bonta, Chair

ABPCA Bill Id:AB 517

Author:(Krell) – As Introduced Ver:February 10, 2025

SUBJECT: Medi-Cal: complex rehabilitation technology: wheelchairs.

SUMMARY: Prohibits the Department of Health Care Services (DHCS) from requiring certain criteria to be met prior to Medi-Cal payment for repair of complex rehabilitation technology (CRT), generally powered wheelchairs and related mobility products. Specifically, this bill:

1. Prohibits DHCS from requiring prior authorization under Medi-Cal for the repair of a CRT powered wheelchair if the cost does not exceed $1,250.
2. Prohibits DHCS from requiring, as part of a treatment authorization request (TAR) process, a prescription or documentation of medical necessity from the treating practitioner requesting the repair or replacement, if the CRT powered wheelchair has already been approved for use by the patient.
3. Requires, for repair of a CRT powered wheelchair in Medi-Cal, a supplier to document and maintain records of the items being repaired, the reason for the repair, and the labor details associated with the repair in the supplier’s files. Provides this documentation must be available upon request by, and may be subject to a post-payment audit conducted by, DHCS.
4. Requires a supplier, if a CRT-powered wheelchair is not already on file with the Medi-Cal program, to ensure that the equipment and related repair details are recorded in a manner that demonstrates proof of continuous medical need. Requires, once the CRT powered wheelchair is recorded, any subsequent repairs to follow the process outlined in 1) through 3), above.

EXISTING LAW:

1. Establishes the Medi-Cal Program, administered by DHCS, to provide comprehensive health benefits to low-income individuals who meet specified eligibility criteria. [Welfare and Institutions Code (WIC) § 14000 et seq.]
2. Establishes a schedule of benefits under the Medi-Cal program. [WIC § 14132]
3. Makes durable medical equipment (DME) and medical supplies a covered Medi-Cal benefit, subject to utilization controls. [WIC § 14132(m)]
4. Defines “complex rehabilitation technology” as items classified within the federal Medicare Program as of January 1, 2021, as DME that are individually configured for individuals to meet their specific and unique medical, physical, and functional needs and capacities for basic activities of daily living and instrumental activities of daily living identified as medically necessary. These items include, but are not limited to, complex rehabilitation manual and power wheelchairs, power seat elevation or power standing components of power wheelchairs, seating and positioning items, other specialized equipment such as adaptive bath equipment, standing frames, gait trainers, and specialized strollers, and related options and accessories. [WIC § 14132.85(a)(2)]
5. Establishes accreditation and quality standards for Medi-Cal providers of CRT. [WIC § 14132.85(b)]
6. Authorizes DHCS to adopt utilization controls, as appropriate, including but not limited to a specialty evaluation by a qualified health care professional, as defined. [WIC § 14132.85(e)]
7. Defines prior authorization and TARs in Medi-Cal. Requires a provider submitting a TAR to explain why the services are medically necessary or submit supporting documentation indicating medical necessity. [Title 22, California Code of Regulations § 51003]

FISCAL EFFECT: Unknown. This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill aims to eliminate barriers to timely repairs for Californians who depend on powered wheelchairs for their independence. By removing the requirement for prior authorization for repairs under $1,250 and simplifying documentation, this bill is intended to ensure that individuals with disabilities will have quicker access to the repairs they need to stay mobile and independent. The author indicates this bill addresses critical delays in the repair process, which currently place patients at risk of being without their essential devices for weeks at a time. In addition, the author notes, this bill allows DHCS to conduct post-payment audits to ensure compliance and detect any potential fraud. The author concludes that this bill will help improve the quality of life for individuals who rely on CRT, allowing them to regain their mobility and dignity without unnecessary red tape.
2. BACKGROUND.
   1. CRT. CRT is defined in existing law as noted in 4) of “Existing Law” above. A less technical definition of CRT is provided by the National Coalition for Assistive & Rehab Technology (NCART), the national membership organization of CRT providers: CRT is medically necessary and individually configured products and services designed to meet the unique medical and functional needs of individuals with significant disabilities and medical conditions.

According to NCART, disabilities and medical conditions that cause this level of mobility impairment typically result from a congenital disorder, a progressive or degenerative neuromuscular disease, or from certain types of injury or trauma. In evaluating a person for CRT, consideration is given to the person’s immediate and anticipated medical and functional needs. These needs include, but are not limited to, activities of daily living, functional mobility, positioning, and pressure relief.

CRT products include a variety of types of individually configured manual and power wheelchairs. These products also include a variety of alternative driving controls for power wheelchairs that enable people with significant disabilities to move about and control their environment. CRT also includes related items such as individually configured seat cushions, back supports, trunk supports, molded seating systems, headrests, chest harnesses, hip belts and trays. Other specialized equipment includes standing frames, gait trainers, strollers, car seats, activity chairs, specialized bath chairs and commodes, and specialized walkers.

Because the technology and skills are so specialized, the supply of CRT providers is somewhat constrained. NCART’s website lists 44 total provider locations in California, of which 24 are different locations of two larger companies: NuMotion and National Seating and Mobility. Anecdotally, providers describe struggling to maintain access to these services across the state, with technicians often traveling long distances to people’s homes to assess the need for, and complete, repairs. The average service radius for these companies is 250 miles.

• 1. Medi-Cal Coverage of CRT and Prior Authorization. Medi-Cal reimburses providers for medically necessary CRT. DHCS requires prior authorization through a process called a TAR to ensure the equipment is medically necessary and meets DHCS standards before Medi-Cal will approve payment for the equipment. A TAR is a form that must be reviewed and approved by DHCS before payment for services or equipment is authorized. After submitting a TAR, providers receive an electronic “Adjudication Response” from DHCS letting them know if a service is approved, denied, or modified. A TAR requests documentation and other information that is sufficient to allow for a decision on the medical necessity of the request. DHCS also requires a TAR for repairs of CRT, which is the subject addressed by this bill.
  2. Recent Changes to Medi-Cal CRT Wheelchair Repair Policy and Related Context. According to the author, sponsor, and industry stakeholders, the prior authorization process for repairs on average creates a 21-day delay in service and repairs. The TAR process for repairs is complicated by the requirement to demonstrate medical necessity, which necessitates involvement from the individual’s medical provider, in addition to the CRT provider who actually performs the repair. According to NCART, medical providers often do not have direct knowledge of the mechanical functioning of the equipment that they have deemed medically necessary for their patient, and therefore the involvement of a medical provider adds limited value and significant administrative burden and delay. According to this bill’s sponsor, the California Foundation for Independent Living Centers, when someone with a severe physical disability and impaired mobility experiences a malfunction with their wheelchair or other mobility device, it is often an urgent or even emergency situation, as the individual may be literally immobilized and unable to perform activities of daily living.

SB 271 (Dodd) of 2023 included similar provisions as this bill to address these delays, although the most significant provisions of that bill created a “right to repair” for wheelchair owners and independent repair agencies. SB 271 had similarly sought to streamline the repair process for powered wheelchairs by removing prior authorization requirements for repairs under $1,250 and simplifying the documentation needed from treating practitioners. SB 271 was vetoed by Governor Newsom, who cited the need for cost containment and potential for abuse. The veto message, however, instructed DHCS to review and consider updating the authorization process for CRT powered wheelchairs. In response, in October 2024, DHCS updated its policy regarding prior authorization for CRT wheelchairs, as reflected in the Medi-Cal provider manual under the title, “Durable Medical Equipment (DME): Bill for Wheelchairs and Wheelchair Accessories.” The new policy replaced prior authorization with retrospective authorization for most repairs under $1,250 per month. Under the new policy, for CRT repairs under Medi-Cal, repairs that cost $250 or more but less than $1250 require a retrospective authorization, which means the provider may begin the repair before receiving approval, but DHCS will review the service after the fact. At that time, after the repair is complete, DHCS may decide to authorize or deny payment. For repairs above $1250, prior authorization is required before services are rendered. Repairs under $250 do not require prior authorization.

While this change was intended to speed up repairs, NCART insists it does not resolve the issue since providers indicate they cannot take on the financial risk of repairs without the guarantee of payment. As a result, according to NCART, the delays and administrative burden that SB 271 aimed to address remain unresolved despite DHCS’s recent policy updates. This bill would instead streamline the process for providers and Medi-Cal enrollees by eliminating the authorization process entirely for repairs under $1,250, but making repairs subject to post-payment audit, where DHCS could review and potentially recoup payments from providers for services that do not meet DHCS standards.

• 1. Medicare Policy. The federal Medicare program also covers CRT. The “Centers for Medicare and Medicaid Services (CMS) - Medicare Program Integrity Manual, Chapter 5: Durable Medical Equipment (DME)” states documentation is required from the treating practitioner that indicates the wheelchair being repaired continues to be medically necessary. For this purpose, documentation is considered timely when it is on record in the preceding 12 months, unless otherwise specified. However, it does not appear to require a provider to verify medical necessity of the repair itself.

1. SUPPORT. In addition to California Foundation for Independent Living Centers (CFILC), this bill’s sponsor, this bill is supported by disability rights and consumer advocates, as well as CRT providers. CFILC states this legislation enables repair providers to expedite the repair process and avoid needless delay, helping to maintain critical mobility for disabled Californians who rely on powered wheelchairs. NCART argues the October 2024 update to Medi-Cal guidance not only jeopardizes the financial viability of CRT providers, but it does nothing to fix the unnecessary prior authorization process. NCART states this bill will take a meaningful step towards addressing the current prior authorization challenges providers face in providing timely repairs.
2. RELATED LEGISLATION. A large number of bills this year are seeking to address various issues related to prior authorization and utilization review in the commercial market and Medi-Cal program, which consumers and providers say impedes access to care in various ways. These bills include: AB 384 (Connolly), AB 510 (Addis), AB 512 (Harabedian), AB 539 (Schiavo), AB 574 (Mark González), and AB 669 (Haney), which are all pending in the Assembly Health Committee, and SB 306 (Becker), which is pending in the Senate Health Committee.
3. PREVIOUS LEGISLATION. SB 271 (Dodd) of 2013 was similar to this bill but also included a “right to repair” for wheelchair owners and independent repair agencies. SB 271 was vetoed by Governor Newsom, who cited the need for cost containment and potential for abuse.

REGISTERED SUPPORT / OPPOSITION:

Support

California Foundation for Independent Living Centers (sponsor)

ALS Association

California Association of Medical Product Suppliers

California Chronic Care Coalition

California Coalition on Family Caregiving

California Commission on Aging

California Medical Association (CMA)

Clinician Task Force

Family Caregiver Alliance (FCA)

Freedom Mobility Center

International Registry of Rehabilitation Technology Suppliers

Invacare

Merits Health Products, INC.

Mobility Solutions

National Coalition for Assistive & Rehab Technology (NCART)

National Health Law Program

National Seating & Mobility

New West Medical INC.

Premier Medical

Reliable Medical

Resna

VGM & Associates

Western Center on Law & Poverty, INC.

Yolo County In-home Supportive Services Advisory Committee

Opposition

None on file.

Analysis Prepared by: Lisa Murawski / HEALTH / (916) 319-2097