Alberta Health. AADL Approved Product List- Wheelchairs: Manual and Power Pricing effective October 1, 2017 Revised December 4, 2017

Transcription

1 Alberta Health Manual Wheelchairs Adult Category A.... APL W-1 Adult Category B.... APL W-3 Adult Category C/D APL W-4 Adult Category A Heavy Duty/Extra-Wide APL W-5 Adult Tilt-in-Space/Recline.. APL W-6 Pediatric Wheelchairs.. APL W-8 Manual Wheelchair Options:..... APL W-9 Power Wheelchairs Adult APL W-10 Pediatric..... APL W-11 Power Tilt and ialty Controls.. APL W-12 Wheelchairs: Discontinued..... APL W-13 Approved Product List- Wheelchairs: Manual and Power Pricing effective October 1, 2017 Revised December 4, 2017

2 WHEELCHAIRS Wheelchairs are Recycle Benefits: Wheelchairs funded by and are no longer required by the client are returned to an vendor to be recycled except Upgrade wheelchairs that are considered as client owned. Eligibility: Wheelchair eligibility is based on usage and clinically assessed needs which determines the category funded by. See eligibility under each category. Costs: Clients are responsible for any upcharges or options not funded by. These are listed on the individual wheelchair spec s available on the website. Adult Clients preferring a higher category (B or C) than they are eligible for are handled as upgrade wheelchairs; a grant of $ (subject to cost-share) may be provided toward the purchase. All funded wheelchairs must meet the equipment standards listed below. Clients are responsible for all maintenance, parts changes and repairs on upgrade wheelchairs (refer to Policy WM-Manual for details). Equipment Standards for all funded Wheelchairs: Wheelchairs must meet RESNA standards. Product on the North American market for a minimum of one year. Manufacturer must have an active representative in the province available for consult. Distribution of equipment is through Approved s with a facility maintained in Alberta. Parts must be available from a Canadian Distributor warehouse. Minimum warranties: 5 years on frame and 12 months on wheels and casters. MANUAL WHEELCHAIRS: ADULT CATEGORY A Category A wheelchairs have a weight capacity of 250 lbs. unless otherwise stated. Funding for additional options on wheelchairs are separated and are found under Wheelchair Options benefit codes on page APL W-9. Clients must be willing to accept a comparable substitute for Category A wheelchairs. Eligibility Category A: Part time wheelchair use or full time indoor use with occasional outdoor use or for use as back-up when power wheelchair is in for repairs. Clinical rationale must be written on the 1251 form for the following options: One Arm Drive, Heavy Duty package, elevating legrests, adjustable tension back, angle adjustable foot plates. Basic Price: based on seat width (15-18 ) x depth (16-18 ), 24 mag wheels, adjustable height armrests, 8 casters, composite handrims, standard 70 footrests, angle adjustable back canes, urethane tires and anti-tippers. This price is used for comparison purposes only and is not the final cost of an individualized wheelchair order. Costs: Max.funding paid by for an adult Category A wheelchair is $ Client costs are calculated on the Standardized Sheets for the W/C s below. W130 W151 W153 Manufacturer/Model Description Color Breezy 600 Ki Mobility Catalyst 4 Power Plus Voyageur Plus Can accommodate One Arm Drive Standard Crossbraces only. Can accommodate HD package. See Heavy Duty package codes APL W-9 Can accommodate HD package. See Heavy Duty package codes APL W-9 Basic Price or 18 8% $2249 Oct 1/ % $2140 Oct 1/17 Black % $1690 Oct 1/17 Revised December 4, 2017 APL W-1

3 MANUAL WHEELCHAIRS: ADULT CATEGORY A Category A wheelchairs have a weight capacity of 250 lbs. unless otherwise stated. Funding for additional options on wheelchair are separated and are found under Wheelchair Options benefit codes on page APL W-9. Clients must be willing to accept a comparable substitute for Category A wheelchairs. Eligibility: Category A: Part time wheelchair use or full time indoor use with occasional outdoor use or for use as back-up when power wheelchair is in for repairs. Basic Price: Based on seat width (15-18 ) x depth (16-18 ), 24 mag wheels, adjustable height armrests, 8 casters, composite handrims, standard 70 footrests, angle adjustable back canes, urethane tires and anti-tippers. This price is used for comparison purposes only and is not the final cost of an individualized wheelchair order. Costs: Maximum funding paid by for an adult Category A wheelchair is $ , subject to cost share and including vendor discount. W270 W273 W274 W655 W693 W694 W888 W996 Client costs are calculated on the Standardized Sheets for the W/C s below other than W996. Manufacturer/Model Description Color Maple Leaf Swift Maple Leaf NRG+ Gold Maple Leaf NRG+ Pride Lifestream XF Ltd 9000 XT 9000 XT Hemi Myon Category A Upgrade Basic Price Clinical justification required for 16 frame depth by construction. Black % $2240 Oct 1/17 Clinical justification required for 16 frame depth by construction Black % $2040 Oct 1/17 Clinical justification required for 16 frame depth by construction Black % $2140 Oct 1/17 Accommodates OAD Black % $2265 Oct 1/17 No adjustable caster journal or offset bracket, accommodates OAD No adjustable caster journal or offset bracket, accommodates OAD Accommodates OAD Maximum Weight Capacity = 275 lbs. ADULT Client eligible for Category A and chooses a higher category w/c from B or C models on program. Grant of $ towards purchase subject to cost share. Remainder: client cost including repairs. Blue Blue % $2135 Oct 1/ % $2135 Oct 1/17 Black % $2019 Oct 1/17 Any Any See specific model $2000 See ific model Revised December 4, 2017 APL W-2

4 MANUAL WHEELCHAIRS: ADULT CATEGORY B Funding for additional options on wheelchairs are separated and are found under Wheelchair Options benefit codes on page APL W-9. Eligibility: Category B: Full time wheelchair use, independent mobility (able to self-propel indoors and outdoors) and has a risk of U/E overuse/injury. Basic Price: Based on seat width (15-18 ) x depth (16-18 ) w/c with 24 mag wheels, adjustable height armrests, casters, composite handrims, standard footrests and back. Maximum funding paid (for Category B clients) for a Category B wheelchair is $ subject to cost share and including vendor discount. Costs: Clients are responsible for any upcharges or options not funded by. These are listed on the individual wheelchair spec s available on the website. W117 W133 W138 W146 W154 W997 Manufacturer/Model Description Color Quickie QXi Quickie GP/GPV Zippie GS Pride Lifestream XF Ki Mobility Tsunami AL Category B Upgrade Folding Frame. Rigid Frame. Indicate Swing away footrest design or Standard foot cage. Folding w/c. Accommodates OAD option. Reverse configuration possible. Clinical justification on 1251 for extralong/extra-large frame. Folding w/c. Hemi Frame available. 22 width available with HD pkg. Rigid frame. No flat free inserts. No frog legs suspension. ADULT Client eligible for Category B and chooses a higher category w/c from C models on program. Grant of $ towards purchase. Remainder: client cost including repairs. Any Basic Price % Oct 1/ % $3389 Oct 1/ % $3263 Oct 1/ % $3175 Oct 1/ % $2934 Oct 1/17 Any See specific model $2000 See specific model Revised December 4, 2017 APL W-3

5 MANUAL WHEELCHAIRS: ADULT CATEGORY C Funding for additional options on wheelchair are separated and are found under Wheelchair Options benefit codes on page APL W-9. Eligibility: Category C: Full time wheelchair use, independent mobility (able to self-propel indoors and outdoors) and has a risk of U/E overuse/injury In addition, the client frequently (and independently) goes out in the community at least 4/7 days a week. Basic Price: based on 18 x 18 w/c with wheels, casters, armrests, footrests and back. Maximum funding paid (for Category C clients) for a Category C wheelchair is $ subject to cost share and including vendor discount. Costs: Clients are responsible for any upcharges or options not funded by. These are listed on the individual wheelchair spec s available on the website. Costs above this amount are the responsibility of the client. Repairs are covered by when has paid 51% of the cost of the wheelchair. W147 W149 W156 Manufacturer/Model Description Color Ki Mobility Catalyst 5 Crossfire Motion Composite Helio C2 Folding. Standard crossbraces only. 70 or 80 degree angle front footrests Carbon Fiber Frame MANUAL WHEELCHAIRS: ADULT CATEGORY D Basic price % $3121 Oct 1/ % $4027 Oct 1/ % $4225 Oct 1/17 Eligibility Category D: Adults only - full time wheelchair use, independent mobility (able to self-propel indoors and outdoors) and has a risk of U/E overuse/injury In addition, the client frequently (and independently) goes out in the community at least 4/7 days a week. Requests from clients eligible for Category C Wheelchairs for the higher level category D wheelchairs are considered and funded as Upgrade Wheelchairs see Policy WM-Manual. Repairs for Upgrade wheelchairs are the responsibility of the client. Wheelchairs provided under Category D must meet the wheelchair standards listed on page W-1. W998 Description Color Size Lightweight or Ultra-lightweight wheelchair, designed for use by individuals who are very independent and active. Price Any Any $ Client costs Cost share (unless exempt) plus all costs above $ Revised December 4, 2017 APL W-4

6 MANUAL WHEELCHAIRS: ADULT HEAVY DUTY/EXTRA WIDE Category A Heavy Duty wheelchairs have a weight capacity of 350 lbs. unless otherwise stated. Funding for additional options on wheelchairs are separated and are found under Wheelchair Options benefit codes on page APL W-9. Sizing is in 1 increments unless otherwise indicated* (indicates 2 increments) Eligibility: Part time or full time wheelchair use or for use as back-up when power wheelchair is in for repairs. Costs: Clients are responsible for any upcharges or options not funded by. These are listed on the individual wheelchair spec s available on the website. Max. Wt. Manufacturer/Model Description Color Capacity W155 W272 W320 W689 W691 W699 W848 W849 Myon Active Maple Leaf Swift Extra Wide PDG Eclipse Topaz 9000 XDT 9000 XT X-Wide M6 Quickie Bariatric Physipro XL5 - ci Can accommodate OAD. Accommodates HD packages 1-3. See APL W-3 separate codes for HD packages and wt. capacities. 600 lbs. maximum wt. capacity 750 lbs. maximum wt. capacity 600 lbs. maximum wt. capacity Accommodates HD packages. See separate codes for HD packages and wt. capacities. 350 lbs % Oct 1/ lbs. Black % Oct 1/ lbs. 22 up % Oct 1/ lbs. Silver Vein * * 8% Oct 1/ lbs. Cobalt 250 lbs. midnight * % Oct 1/ % Oct 1/ lbs * * 8% Oct 1/ lbs. Black % Oct 1/17 Revised December 4, 2017 APL W-5

7 MANUAL WHEELCHAIRS: ADULT TILT-IN-SPACE Tilt-in-Space wheelchairs are provided to clients who are unable to maintain a sitting position with any other back types or seating devices. Eligibility: Tilt-in-Space wheelchairs must be supported by a Manual Tilt-in-Space Form to confirm eligibility. Clients must be willing to accept a comparable substitute for Tilt-in-Space wheelchairs. Maximum Wt. Capacity: 250 lbs. unless otherwise stated. Costs: Clients are responsible for the costs of any options not funded by. These are listed on the individual wheelchair spec s available on the website. Basic Price includes standard features. pays $ or 51% of the costs for an T-I-S/Recline (subject to cost-share) whichever is greater to maintain ownership of all Tilt-in-Space wheelchairs. Sizing is in 1 increments unless otherwise indicated* (indicates 2 increments) W324 W330 W339 W132 W277 W321 Manufacturer/Model Description Color Future Mobility Orion II Breezy Relax 2 Tilt My Life Health Avenger Tilt Quickie TS Maple Leaf Super Tilt or Dynamic Super Tilt PDG Stellar Tilt Elevating legrests. Not designed for rugged use. Recline feature not funded. No contracture seat frame measured armrest to armrest Rigid Frame. Standard and HD size Dynamic ST requires justification Max tilt on ST 45, on Dynamic 30. See s for HD wt. caps. Rigid frame, accommodates HD package. No dynamic rocker back No 12 wheels. silver Basic Price % $1950 Oct 1/17 Black % $2096 Oct 1/17 Black % $1975 Oct 1/17 Black Black % >$2100 Oct 1/ % >$2100 Oct 1/17 5% >$2100 Oct 1/17 Revised December 4, 2017 APL W-6

8 W322 W323 W326 W329 W653 W635 MANUAL WHEELCHAIRS: ADULT TILT-IN-SPACE (continued) Manufacturer/Model Description Color PDG Bentley PDG Bentley Express Quickie Iris PDG Stellar Express PDG Fuze T50 Express Solara 3G Tilt Justification: Athetoid/Chorea/Agitated client 20 manual tilt feature. No long frame or Rear Floor Jack. Accommodates HD package. Standard configuration for backrest/headrest No substitutes Wheels/casters No substitutes No contracture seat frame Standard configuration for cushion, backrest/headrest no substitutes Standard configuration for cushion, backrest/headrest. No substitutes. Generic headrest/backrest provided on recycle outs. Black Black Blue shimmer MANUAL WHEELCHAIRS with RECLINE Basic Price 5% >$2100 Oct 1/17 5% >$2100 Oct 1/ % >$2100 Oct 1/ % >$2100 Oct 1/17 Black % >$2100 Oct 1/17 Black % >$2100 Oct 1/17 Eligibility: Recline wheelchairs must be supported by a Manual Tilt-in-Space Form with Recline section completed to confirm eligibility. Maximum Wt. Capacity: 250 lbs. unless otherwise stated W276 Maple Leaf NRG+ Recliner Black % Oct 1/17 W671 Lightweight Jymni Recliner Maximum weight capacity 125 lbs. Black % Oct 1/17 W XT Recliner Lift package additional cost Wet black Cobalt ,16, % Oct 1/17 Revised December 4, 2017 APL W-7

9 MANUAL WHEELCHAIRS: PEDIATRIC Eligibility: Category A: Part time wheelchair use or full time indoor use with occasional outdoor use or for use as back-up when power wheelchair is in for repairs. Under the age of 18 years. Family of the client must be willing to accept a comparable substitute for Category A wheelchairs. Must check off independent mobility (self-propelling) to be eligible for pediatric rigid frame wheelchairs. Price reflects cost of a basic wheelchair with wheels, armrests, standard footrests and back. Sizing is in 1 increments unless otherwise indicated. MANUAL WHEELCHAIRS: PEDIATRIC CATEGORY A W115 W116 W133 W138 W117 W118 W137 W157 W145 W653 W683 W684 Manufacturer/Model Otto Bock Start Junior Physipro XL5 Express Quickie GP/GPV Zippie GS Quickie QXi Quickie Zippie Zone Quickie 2 Ki Mobility CLIK Zippie Iris PDG Fuze T50 Express Freedom P.R.O Freedom NXT Description Folding frame, black upholstery Maximum wt. capacity 198 Folding frame. Angle adjustable back to 15. Rigid frame. Swing away footrest design or standard foot cage. Folding w/c. OAD option. Reverse configuration possible. Max. Wt. Cap. Revised December 4, 2017 APL W-8 Color 198 lbs. Yellow % Oct 1/ lbs. Black % Oct 1/ lbs. 250 lbs. MANUAL WHEELCHAIRS: PEDIATRIC CATEGORY B Folding frame Rigid frame Straight frame (folding only) sizes over 16 not funded. Rigid frame, Hybrid offset frame available. 265 lbs. 165 lbs % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/ lbs % Oct 1/ lbs. MANUAL WHEELCHAIRS: PEDIATRIC TILT Rigid Frame No contracture seat frame 150 lbs. opal % Oct 1/ % Oct 1/17 Junior rigid frame 209 lbs. Red % Oct 1/17 Accommodate L/E deformities Handbrakes Folding Tilt. Handbrakes. Accommodate L/E deformities 250 lbs. 225 lbs % Oct 1/ % Oct 1/17

10 MANUAL WHEELCHAIRS OPTIONS ON ADULT WHEELCHAIRS Eligibility: Category A/B/C except grants and Tilt-in-Space wheelchairs. Heavy Duty Package: Client s weight must support request for Heavy Duty (HD) Packages (e.g. client s must weigh more than 250 lbs. to be eligible for HD1, more than 350 lbs. to be eligible for HD2, etc.) One Arm Drive (OAD): Client must have a unilateral U/E impairment. Independent mobility (self-propelling) must be checked off on 1251 to be eligible for one arm drive. Rationale must be written on the 1251 for OAD and/or HD packages. Rationale for HD includes weight; rationale for OAD includes the reason why the client has the use of only one upper extremity. Confirm client is self-propelling with OAD. Not all wheelchairs accommodate HD packages or OAD. Ensure the model chosen is appropriate if adding either of these options. Costs: Clients are responsible for costs over the maximum price. Costs for HD packages and OAD are listed on individual spec s for each wheelchair on the program. Manual Wheelchair Option Description W101 HD1 - Heavy Duty Package Includes HD crossbraces, HD casters, HD upholstery & rigidizer bar W102 HD2 - Heavy Duty Package HD2 Includes double crossbraces, gusseted side frames, HD upholstery reinforced back posts and HD forks/casters. W103 HD3 - Heavy Duty Package HD3 Includes double crossbraces, gusseted side frames, HD upholstery reinforced back posts and HD forks/casters. May include a rigid frame on some models. Maximum Weight Capacity Maximum Price 350 lbs. $ lbs. $ lbs. and more $ W104 OAD - One Arm Drive - Standard wt. or HD 250 lbs. or more $ W105 OAD - One Arm Drive for Tilt-in-Space 350 lbs. or more $ W106 EL/AEL - Elevating Leg Rests Articulating or non-articulating $ W107 AAF- Angle Adjustable Footplates $ W108 ADJ-Adjustable Tension Back Standard Sizes $ W109 ADJ-Adjustable Tension Back - Oversize $ W110 Oxygen Holder Replaces Z990 note single holder is $ and double is $311. $ Revised December 4, 2017 APL W-9

11 POWER WHEELCHAIRS Eligibility: A Power Wheelchair Application is reviewed to determine if a client is eligible for power mobility. Tilt options eligibility is determined by the Tilt-in-Space Form attached to the application. All power wheelchairs must be prior approved by. Refer to the Policy Manual for details on eligibility. Clients must be willing to accept a comparable substitute for power wheelchairs to be eligible for funding. Contoured backs must be ordered through the seating clinic to be eligible for funding. The tilt option is funded for Adult clients only. High Speed Motors are not covered by. Costs: Clients are responsible for any upcharges or options not funded by. These include seat elevators, power elevating legrests and foot platforms. See the WPmanual for a complete list of options not covered by. Other options may be covered depending on clinical rationale. See W100 for ialty Control coverage. Warranties: Batteries: 1 year; Actuators: 18 months; Controllers/Joysticks/Motors: 3 years (manufacturers have until October 2018 to comply). W558 W579 W581 W592 W659 W663 W677 W709 W714 W801 Manufacturer/Model Arrow Storm Quickie S646SE QM-710 Pride Mobility Q6 Edge Pride Mobility Q6 Edge Z Pride Mobility Quantum Rival Xplore Pride Mobility Quantum HD 1450 Pronto Storm TDX-SP POWER WHEELCHAIRS: ADULT Description 4 pole motors only. 400 lbs. wt. capacity as option. Provided without tilt option only. Does not accommodate retro fit tilt. HD model available (450 lbs.wt.cap.) Heavy Duty model for clients over 400 lbs. Max. wt. capacity 650 lbs. Heavy Duty model for clients over 400 lbs. Max. wt. capacity 500 lbs. Wheel Drive Color rear 17p % Oct 1/17 Rear Mid Mid Mid Rear Rear Front Mid Mid % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/17 Revised December 4, 2017 APL W-10

12 POWER WHEELCHAIRS: PEDIATRIC Eligibility: A Power Wheelchair Application is reviewed to determine if a client is eligible for power mobility. All power wheelchairs must be prior approved by. Refer to the Policy Manual for details on eligibility. Clients must be willing to accept a comparable substitute for power wheelchairs to be eligible for funding. The tilt option is funded for Adult clients only for those who qualify. Costs: Clients are responsible for any upcharges or options not funded by. These are listed on the individual power wheelchair spec s available on the website and include seat elevators, power elevating legrests, and foot platforms. The tilt option is not funded for pediatric clients. Other options may be covered depending on clinical rationale. See W100 for ialty Control coverage on page APL W-12. See the WP-manual for a complete list of options not covered by. W577 W594 W657 W677 W803 Manufacturer/Model ZM-310 Pride Quantum J6 TDX Spree Xplore Storm TDX-SC Description Wheel Drive 165 lbs. maximum wt. capacity Mid 250 lbs. maximum wt. capacity Mid 165 lbs. maximum wt. capacity Mid Client must be between yrs.old No contour back Client must be between yrs.old 250 lbs. maximum wt. capacity Rear Rear Color % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/ % Oct 1/17 Revised December 4, 2017 APL W-11

13 POWER WHEELCHAIRS: POWER TILT AND SPECIALTY CONTROLS Eligibility: All power wheelchair options must be prior approved by. Power Tilts are funded for Adult clients only and must be supported by a Power Tilt in Space Assessment Form. Refer to the Policy Manual for additional details on eligibility. Clients funded for ialty Controls own the controls and must be willing to accept responsibility for repairs. Clients are provided with one type of control only. Only one type of specialty control is funded. A client is not funded for both a basic joystick and specialty control. Requires a separate 1251 form when option is provided as a retro-fit. Costs: Clients are responsible for any upcharges or options not funded by. Options for each type of power wheelchair on the program are listed on the individual power wheelchair spec s available on the website. See the WP-manual for a complete list of options not covered by. SPECIALTY CONTROL OPTION Description W100 ialty Controls: Includes: Head Arrays, MEC Joysticks, Chin Controls, Rim Control, Sip n Puff controls and Switch Drives (e.g. 5 switch option with display). Maximum price includes mounting hardware and installation. TILT OPTION discount Maximum Price $4, Oct 1/17 W990 Power Tilt 6% n/a W991 Pride True Balance Power Tilt 6% n/a W992 Power Tilt 6% n/a Revised December 4, 2017 APL W-12

14 Manufacturer/Model Description Reason Discontinu ed Date eff. date W119 KiMobility Little Wave Ped Cat B Discontinued due to cost to grow, replaced with Jan 1/17 KiMobility CLIK W122 Quickie 2 Adult Adult Cat B Jan 1/15 Jan 1/14 W127 Quickie Lxi Adult Adult Cat A Replaced by Qxi Jan 1/15 Jan 1/14 W129 Zippie TS Peds Tilt Replaced with Freedom NXT Jan 1/17 W131 Quickie Lxi Peds Peds Cat B Jan 1/15 Jan 1/14 W135 Quickie Kidz Peds Cat B Replaced by Zippie Zone Jan 1/15 Jan 1/14 W148 Breezy RubiX2 Cat A HD Replaced by Physipro XL5-ci W275 Maple Leaf EZRide Discontinued, not ordered W327 Quickie GT Peds Cat C Jan 1/17 Jan 1/15 W623 Spree XT Peds Tilt Replaced with Freedom PRO Jan 1/17 W632 Spree 3G Jan 1/15 July 1/14 W669 Experience Power Replaced by Zippie ZM-3/Q6Edge Z Jan 1/15 Jan 1/14 W659 Pride Quantum 6000Z Adult Power Replaced by Q6Edge Z Jan 1/15 Jan 30/14 W991 Pride True Balance Tilt 2 Replaced with True Balance 3 Jan 1/15 W994 Ranger Power Tilt Discontinued by Manufacturer Jan 1/17 W280 ML Super Tilt Rock&Roll Adult tilt Discontinued by Manufacturer, not ordered. Dec 1/17 Revised December 4, 2017 APL W-13