Class Action Challenges Kaiser’s Exclusion of Wheelchairs as Covered Essential Benefit

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A proposed class action aims to challenge the California Department of Managed Health Care’s (DMHC) allegedly discriminatory exclusion of certain manual and power wheelchairs as an essential benefit under the Kaiser Foundation Health Plan. 

Filed by two plaintiffs alongside the non-profit California Foundation for Independent Living Centers, the 27-page lawsuit moreover contends that the DMHC’s $2,000 annual cap and “home use” rule pertaining to coverage for medically necessary wheelchairs can leave those with disabilities “bankrupt, immobile, and/or resorting to the use of an inferior or broken wheelchair that puts their health and safety at risk.” 

According to the filing, the defendants—California DMHC Director Mary Watanabe, the California DMHC, Kaiser Foundation Health Plan and Kaiser Foundation Health Plan Northern California Region—have run afoul of the Affordable Care Act, which requires all individual and small group health plans to cover essential health benefits, including “rehabilitative and habilitative services and devices,” without exclusions or annual dollar limitations. 

“The actual cost of a medically necessary wheelchair can exceed $40,000—meaning that people with disabilities must either seek alternative sources of health insurance coverage; pay the remaining cost out-of-pocket, if they can; or go without the mobility device that they need,” the complaint says. 

Under the “home use” restriction, Kaiser will only cover the costs of wheelchairs that are intended and appropriate for use inside of an insured’s home, the case relays, arguing that this is problematic and contrary to ACA rules in that, “if an individual can move around their home with a walker or by crawling, but they need a wheelchair to travel even 15 feet outside their home, then the wheelchair would not be covered.”

One plaintiff requires a power wheelchair that costs in excess of $8,000, while the other requires one that costs $17,000, according to the complaint. 

Per the suit, a key component of the ACA is the prohibition on discrimination in health programs or activities receiving federal financial assistance on the basis of race, color, national origin, sex, age and disability. This ban includes discrimination in a health plan’s “benefit design,” i.e., the structure and content of a health benefits package, the lawsuit says, adding that the California DHMC is responsible for enforcing the ACA’s non-discriminatory benefit design standards in the state.

The case says, however, that the DHMC’s regulations provide that only a “narrow” list of durable medical equipment is required to be covered as essential health benefits, including: 

• Standards curved handle or quad cane and replacement supplies;
• Standard or forearm crutches and replacement supplies;
• Dry pressure mattress pad;
• IV pole;
• Enteral pump and supplies;
• Bone stimulator;
• Cervical traction;
• Phototherapy blankets for treatment of jaundice in newborns; and
• Dialysis care equipment.

The lawsuit adds that coverage for the above items is limited to only those intended for use in an individual’s home. No explanation is given as to why wheelchairs, which the case stresses are “a quintessential [durable medical equipment] item on which thousands of disabled Californians rely for basic mobility” are excluded from coverage as essential health benefits, the lawsuit says. 

“DMHC does not explain, or even make mention, of this omission, even though wheeled mobility devices make up the greatest portion of assistive devices in use and even though independence in mobility is one of the most important determinants of quality of life for individuals with disabilities,” the case reads.

The lawsuit looks to represent all persons with disabilities who are or who will be enrolled in or covered by an individual or small group qualified health plan administered by Kaiser Foundation Health Plan, Inc. in the state of California and who need or will need a wheelchair or wheelchair repair.

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