We often get asked if Medicare will pay for the home medical equipment customers are looking at in our Dallas store. In many cases, Medicare can cover the item, however, the person has to qualify for the equipment first. Long gone are the days when all you needed was a prescription from your physician to pick up the equipment. Now, Medicare requires forms filled out by the physician proving the patient qualifies for a durable medical equipment (DME) company to provide the item. In many instances, additional documentation is required, such as a face-to-face visit with the physician where they incorporate your qualifications into the medical record. If the patient meets all the qualifications for the item, and have Part B Medicare, Medicare will cover 80% of the fee, leaving 20% to secondary insurance or for the individual to pay.
This can be overwhelming, and it is hard to know what is or is not covered by Medicare. To make it a little bit easier, we composed of a list of the most popular medical equipment products at CVI Medical and the Medicare qualifications.
A quick reminder, CVI Medical does not file with any insurance provider. We are happy to show you items and discuss qualifications and steps you may need to go through before getting the equipment. The best part about shopping at CVI Medical is that you can receive your equipment that very day by paying for it out of pocket.
Hospital Beds
Does Medicare Cover a Full Electric Hospital Bed?
Medicare does not cover a Full Electric Hospital Bed because they view the height adjustment feature as a convenience feature and thus it will be denied as not reasonable and necessary.
At CVI Medical, we know how important the use of the height adjustment feature is to assist individuals getting in and out of bed or lowering close to the floor for people at risk of falling. If you find you or a loved one in need of a full electric hospital bed, we can be out quickly with a rental or purchase.
Does Medicare Cover a Semi Electric Hospital Bed?
Medicare will cover a Semi Electric Hospital Bed if the patient or “beneficiary” meets the following qualifications:
The beneficiary must:
A.Require frequent changes in body position and/or has an immediate need for a change in body position.
In addition to A, the patient must meet one of the following requirements:
1. Has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed.
2. Requires positioning of the body in ways not feasible with an ordinary bed to alleviate pain.
3. Requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration.
4. Requires traction equipment, which can only be attached to a hospital bed.
If the individual does not meet Medicare qualifications, we rent and sell home hospital beds. Most individuals prefer the full electric hospital bed because the hand control allows the user or caregiver to adjust the height of the bed with a button. A semi electric hospital bed requires someone to crank the bed to adjust its height.
Does Medicare Cover a Heavy-Duty Hospital Bed?
Medicare will cover a heavy-duty/bariatric hospital bed if the patient meets the requirements of a semi electric hospital bed and weighs over 350lbs but less than 600lbs.
Does Medicare Cover a Gel Overlay?
Medicare will cover a gel overlay if the patient has a hospital bed on file with Medicare and meets one of the following criteria:
1. The patient is completely immobile – i.e., the patient cannot make changes in body position without assistance.
2. The patient has limited mobility – i.e., patient cannot independently make changes in body potion significant enough to alleviate pressure and has at least one of the conditions A-D below.
3. The patient has any stage pressure ulcer on the trunk or pelvis and at least one of the these conditions:
A. Impaired nutritional status
B. Fecal or urinary incontinence
C. Altered sensory perception
D. Compromised circulatory status
Does Medicare Cover a Low Airloss Mattress?
Medicare will cover a low airloss mattress if they meet the following criteria. In addition, paperwork for the mattress must be resubmitted monthly for the patient to retain the mattress. If not completed monthly or the patient no longer meets the criteria, Medicare will deny the claim.
The patient must meet at least one of the following criteria:
1. The patient has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the patient has been on a comprehensive ulcer treatment program including each of the following:
a. Use of an appropriate group 1 support surface, and
b. Regular assessments by a nurse, physician, or other licensed healthcare practitioner, and
c. Appropriate turning and positioning, and
d. Appropriate wound care, and
e. Appropriate management of moisture/incontinence, and
f. Nutritional assessment and intervention consistent with the plan of care.
2. The patient has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis.
3. The patient had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 dates.
Bathroom Equipment
Does Medicare Cover Bathroom Equipment?
Medicare does not cover bathroom equipment. This includes toilet seat risers, shower chairs, transfer benches, toilet safety rails, and grab bars.
Does Medicare Cover a Bedside Commode?
Medicare can cover a bedside commode, also known as a 3-in-1 commode, if the patient meets one of the qualifications listed below. However, if the need for the commode is inside the bathroom as a raised toilet seat or shower chair, the commode will not be covered by Medicare.
1. The patient cannot make it to the toilet facilities in a timely manner.
2. The patient is confined to a single room.
3. The patient is confined to one level of the home environment that there is no toilet on that level.
4. The patient is confined to the home and there are no toilet facilities in the home.
Does Medicare Cover a Drop Arm Commode?
Medicare can cover a drop arm commode if the patient requires a commode chair with detachable arms to facilitate transferring the patient, or the patient has a body configuration that requires extra width. For the drop arm commode to be covered, the patient must also meet a qualification of a bedside commode. See above.
Does Medicare Cover a Heavy-Duty Commode?
Medicare can cover a Heavy Duty / Bariatric Commode if the individual meets the criteria of a drop arm commode and weighs over 300lbs.
Lift Chairs
Does Medicare Cover a Lift Chair?
Medicare does not cover the full amount of a lift chair. The seat lift mechanism of the lift chair is the only portion covered while the rest of the chair is considered furniture. If the patient has a wheelchair, power scooter, or power wheelchair on file with Medicare, Medicare will deny the claim. To qualify for Medicare coverage of the seat lift mechanism, the patient must meet all of the following criteria:
A. The patient must have severe arthritis in the hip or knee, or the patient must have a sever neuromuscular disease.
B. The patient must be completely incapable of standing up from a regular armchair or any chair in his/her home.
C. Once standing, the patient must have the ability to ambulate.
D. The patient must document in their medical records all the tried and failed therapeutic modalities to enable the patient to transfer from a chair to a standing position (medication, physical therapy).
Many of our customers do not qualify for Medicare coverage or even if they do, forego going through the paperwork process. However, we recommend all of our customers to try to get a prescription for the lift chair to remove the tax from the purchase. This can be a savings of over $300 depending on the chair.
Wheelchairs and Transport Chairs
Does Medicare Cover a Manual Wheelchair?
Medicare can cover a manual wheelchair when the patient or “beneficiary” meets all the following criteria:
A. Has a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home.
B. Has a mobility limitation that cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
C. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
D. Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLS and the beneficiary will use it on a regular basis in the home.
E. Has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
F. Has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel in the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
G. Has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
Does Medicare Cover a Lightweight Manual Wheelchair?
Medicare will cover a lightweight manual wheelchair if the patient meets the criteria of a manual wheelchair and is only able to self-propel in a lightweight wheelchair. However, many lightweight wheelchairs are not covered by Medicare because they have not been coded for insurance purposes. These are often the most popular ultra-lightweight wheelchairs that weigh 25lbs and less.
Does Medicare Cover a Transport Chair?
Medicare can cover a transport chair if the person qualifies by meeting the following criteria: the patient must have mobility limitations that significantly impairs their ability to participate in daily tasks around the home, the mobility deficit cannot be sufficiently resolved by the use of a walker, cane, or manual wheelchair, the patient does not have sufficient upper extremity function or other physical or mental capabilities needed to safely self-propel a manual wheelchair, and there must be a caregiver that is able and willing to propel the patient in the transport chair.
Patient Lift
Does Medicare Cover a Hydraulic Patient Lift?
Medicare will cover a hydraulic patient lift if the individual requires a lift to assist in the transfer between the bed and a chair, wheelchair, or commode. Without the lift, the patient would be confined to their bed.
Does Medicare Cover an Electric Patient Lift?
Medicare will cover an electric patient lift if the individual requires a lift to assist in the transfer between the bed and a chair, wheelchair, or commode. Without the lift, the patient would be confined to their bed.
It may be difficult to locate a company who will provide an electric patient lift to a customer through Medicare because the fee is the same as a hydraulic lift, but the patient lift costs twice as much.
Power Scooter / Power Wheelchair
Will Medicare Cover a Power Scooter?
Medicare will cover a power scooter for an individual for use inside their home. The patient must not be able to get around with a walker or manual wheelchair. If the sole purpose for a scooter is for outdoors, or going long distances, Medicare will deny the scooter. In order to qualify for a power scooter, the patient must have limited mobility and meet all of the following conditions:
1. The patient must have a health condition that causes significant difficulty moving around in their home.
2. The patient is unable to do activities of daily living (like bathing, dressing, getting in or out of a bed or chair, or using the bathroom) even with the help of a cane, crutch, or walker.
3. The patient is able to safely operate and get on and off the scooter or have someone with the patient who is always available to help them safely use the device.
4. The patient can use the equipment within the patient’s home (for example, it’s not too big to fit through doorways in their home or blocked by floor surfaces or things in its path).
Will Medicare Cover a Power Wheelchair?
Medicare will cover a power wheelchair if the patient can’t use a manual wheelchair in their home, or if the patient doesn’t qualify for a power-operated scooter because they aren’t strong enough to sit up or to work the scooter controls safely. In addition, they must meet the following qualifications:
1. The patient must have a health condition that causes significant difficulty moving around in their home.
2. The patient is unable to do activities of daily living (like bathing, dressing, getting in or out of a bed or chair, or using the bathroom) even with the help of a cane, crutch, or walker.
3. The patient is able to safely operate and get on and off the power wheelchair or have someone with the patient who is always available to help them safely use the device.
4. The patient can use the equipment within the patient’s home (for example, it’s not too big to fit through doorways in their home or blocked by floor surfaces or things in its path).
Walkers / Rollators
Will Medicare Cover a Walker?
Medicare will cover a walker if the patient has a mobility limitation that significantly impairs their ability to participate in daily activities in their home, the patient must be able to safely use the walker, and that the functional mobility deficit must be sufficiently resolved by the use of a walker. If these criteria are met, Medicare will cover a walker.
Does Medicare Cover a Rollator?
Medicare will not cover a rollator. However, certain aspects of the rollator can be partially covered by billing for a walker, a seat attachment for a walker, and a miscellaneous code to cover the brakes and basket. The brakes and basket are non-covered items that Medicare will not pay for, and the patient is responsible for. The patient must meet the requirements of the walker: the patient has a mobility limitation that significantly impairs their ability to participate in daily activities in their home, the patient must be able to safely use the walker, and that the functional mobility deficit must be sufficiently resolved by the use of a walker. If these criteria are met, Medicare will cover a walker.
Ramps and Other Home Medical Products
Does Medicare Cover Ramps?
Medicare does not cover ramps inside or outside the house. Although your physician may prescribe you ramps or other home modifications to help navigate your home, Medicare will not cover any home modification because it does not fall under the Durable Medical Equipment (DME) benefit of Medicare Part B.
Does Medicare Cover Grab Bars?
Medicare does not cover grab bars, even if they are necessary for safety. Medicare does not cover any home modification.
Does Medicare Cover Incontinence Supplies?
Because incontinence supplies and adult diapers are nonreusable and a hygienic item, Medicare does not cover them. The individual is responsible for full payment.
Does Medicare Cover Compression Stockings?
In most cases, Medicare will not cover compression stockings including as treatment for varicose veins, blood clots, or circulation issues. It is possible to receive coverage as a form of wound care to treat an open venous stasis ulcer or through different Medicare Advantage plans.
Does Medicare Cover Knee Scooters / Knee Walkers?
Medicare does not cover knee scooters / knee walkers although certain Medicare Advantage plans or dual eligibility with Medicaid may offer coverage. The knee scooter does not meet Medicare Part B coverage because Medicare covers crutches, and they serve the same purpose.
Medicare Coverage Overall for Home Medical Equipment
The primary source we use to understand Medicare coverage of the products we offer and the source we used to reconfirm information for this blog article is: https://www.cms.gov/medicare-coverage-database/search.aspx. We also utilize https://www.medicare.org/ which does have some very specific articles such as: https://www.medicare.org/articles/does-medicare-cover-knee-scooters/.
As you can see, what Medicare covers varies. Our expert team at CVI Medical is very versed on what Medicare does and does not cover for you and can provide you with renting and buying guidance on home medical equipment. Stop in our Dallas store or give us a call to discuss your needs and options.