Does Medicare cover bed wedges ?
About 20 months ago my mom had hip surgery at 88 yrs old, and we were trying to work out whether or not she would need some kind of bed rail to stop her from falling out of bed. I did my reading and then discovered that there are lots of alternatives. Bed wedges are a very good way of stopping people form falling out of bed in their sleep, and they don’t cost that much compared to a lot of other equipment.
Does Medicare cover bed wedges ? Medicare Part B does not cover bed wedges as they don’t consider bed wedges to be “medically necessary”. Other programs such as Medicaid, non-Medicaid State Financial Assistance Programs and Assistive Technology Projects may give coverage for bed wedges, if you are eligible.
A great many of the items that our elderly parents will be using in the home to make their lives easier and safer, such as bed wedges will not be covered by Medicare.
Medicare’s criteria for coverage are not that an article be useful, or that it keeps us comfortable, but that it is “medically necessary”.
Bed wedges unfortunately are really safety equipment and Medicare doesn’t cover that.
There are two things that you have to take into account if an item is going to qualify for coverage by Medicare, aside from the fact that you need to be enrolled in the Medicare program –
- is your item in the category of equipment considered for coverage by Medicare – Durable Medical Equipment ?
- is your item “medically necessary” in your case ? – this will be decided by a Medicare-enrolled physician
And don’t forget the Medicare coverage of medical equipment is primarily only for items used in the home.
As I mentioned at the beginning of this post, I did a lot of research into alternatives to bed rails for my mom after a hip replacement surgery.
I put all of that together for you, and your loved ones in an extensive article “Alternatives to bed rails”, outlining the dangers of bed rails to certain individuals who are at risk if you use them, and discussing the safer alternatives, amongst which are bed wedges.
You can read my article here
You are going to discover, if you are your loved ones caregiver, or if you organize it, that a lot of the equipment that you likely thought was covered by Medicare’ is not.
There are other sources of coverage and of funding which are available at a state level, and I will be outlining a number of those as soon as I have dealt fully with Medicare.
To start, I am going to take a look at some other types of safety equipment to broadly outline –
- what is and what isn’t covered
- how to get coverage when it is available
- what procedural mistakes not to make with Medicare
- where to get guidance if you need it – counselors, websites and other resources freely available to you
So does Medicare cover bathroom safety equipment ?
The bathroom, it goes without saying, is probably the room which requires the most safety equipment, as it poses the worst risks for our elderly parents and loved ones. I believe the statistic is that 80% of all falls by the elderly occur in the bathroom.
Medicare is not much help in the bathroom. It will not cover
- grab bars
- non-slip mats
- bath lifts
- shower chairs
- bath chairs
- transfer seats
- raised toilet seats
- toilet safety frames
as it considers these to be comfort items. Not “medically necessary”.
Medicare does though cover walkers, crutches and commode chairs, if they are “medically necessary” and prescribed by a Medicare-enrolled physician.
Happily these items can be used in the bathroom as safety equipment to help from the risk of falling.
I got my mom a 3 in 1 bedside commode, and she has been able to use this as a raised toilet seat, toilet safety rail, a chair for sitting and having a sponge bath in, and also as a bedside commode of course. If we had a larger shower Mom could have also used it as a shower chair.
So, even if you have to pay for a 3 in 1 bedside commode you can save on getting 4 other pieces of equipment at least, and if your doctor deems it “medically necessary”, you have will only pay the 20% Medicare co-payment and your deductible if you have yet met that for the year.
If you want to learn more about bathroom safety and what’s possible, I have a long article with 54 safety tips that I have researched, used over the 11 years that I have looked after my mom and dad. It includes both practical tips, and a range of items you may wish to look at. You can find that here.
If you how to make bathing easier for your parent, I have another article discussing a lot of different things you can do to make it a more comfortable and dignified experience for all parties – you can read that article here.
How often does Medicare pay for a walker, or any other type of equipment that it covers ?
The Medicare Part B coverage policy for DME’s is to replace worn out equipment it covers , once every five years from the date that it was received.
That said, a walker which is worn out under Medicare Part B coverage can be replaced every five years.
Will Medicare pay for walker and a wheelchair ?
On this point Medicare is very clear, it will not cover more than one mobility aid for use in the home.
Does Medicare cover exercise equipment ?
Exercise equipment is not considered “medically necessary” by Original Medicare, and usually neither are exercise classes.
Original Medicare Part B will though cover physiotherapy and occupational therapy where it is prescribed as “medically necessary’ by a physician.
The therapist providing the treatment must be doing so on an outpatient basis, must be Medicare-certified, and the therapy must be regularly reviewed by the prescribing physician.
Just like with equipment you will need to make sure that they charge the Medicare approved amount. Medicare will pay 80% of the Medicare- approved fee and the patient covers the remaining 20%, plus their deductible if it applies.
If you have a Medicare Advantage Plan you may discover that you have coverage for exercise plans and gyms, but you will need to ask your provider.
What happens if I my DME is damaged lost or stolen ?
Equipment covered by Medicare which is lost, stolen or damaged beyond repair, may be replaced.
Source: Medicare coverage of Durable Medical Equipment and Other Devices, CENTERS for MEDICARE & MEDICAID SERVICES.
You can read, or download, the original Medicare document here.
The passage above is on Page 13 of the pdf.
What type of equipment does medicare cover ?
Medical equipment which Medicare affords coverage is called Durable Medical Equipment.
Original Medicare part B covers Durable Medical Equipment, or DME’s “for use in the home”.
Original Medicare Part A (hospital care) covers all aspects of short term treatment in skilled nursing facilities, including DME’s.
For an item to qualify as Durable Medical Equipment Medicare has established the following criteria –
- it has able to withstand repeated use over a sustained period of time – durable
- it must be used for a medical reason only – not for comfort
- it must be of use to someone who is actually sick, and of little use to a person who is well
- it must be used primarily in the home
- it must be expected to last a minimum term of 3 years
How do you qualify for Medicare coverage ?
To qualify for Medicare coverage of DME’s “for use in the home” under Original medicare Part B, you –
- have to be enrolled in Medicare Part B
- have a signed prescription from your Medicare-enrolled doctor stating that your item is “medically necessary”
- have to purchase the item from a supplier who is a Medicare-enrolled supplier
To qualify for “home use” –
You must be –
- living in your own home
- living in the family home
- living in the community, such as assisted living
What do you do with your signed prescription for your DME ?
So now you have your prescription from your Medicare-enrolled physician, it’s time to go see a Medicare-enrolled DME supplier.
Medicare usually only offers the basic versions of any equipment, and a pretty limited range of those. Sometimes if you wish to upgrade you can, but you will pay the extra.
There will be forms to fill out with the supplier.
As you have a prescription from a Medicare-enrolled doctor, Medicare part B covers 80% of the Medicare-approved price for your equipment.
You will typically pay your Medicare 20% co-payment of the Medicare-approved price for your equipment, plus your deductible if it applies as long as you used a Medicare-enrolled “participating” supplier who accepts assignment.
Always ask for, and use, a Medicare-enrolled “participating” supplier who accepts assignment or you could end up paying a lot more than you need to.
Does Medicare purchase or rent DME’s
Some items, usually the less expensive ones, are purchased by Medicare from the supplier, and other more important items, such as a hospital bed, will be paid for on a rental basis.
With a rental, as long as the supplier is a Medicare-enrolled “participating” supplier who accepts assignment, you will pay a monthly 20% co-payment of the Medicare-approved price for the equipment, and your deductible.
What coverage do you get with Medicare Advantage Plans ?
With enrollment in a Medicare Advantage Plan you are covered for all the same medical services, supples and equipment that Medicare Parts A and B cover, and sometimes a few extra services.
You will need to contact your Advantage Plan provider to find out about their exact process for buying items with coverage, the doctors they work with, and their supply network.
Using doctors and suppliers outside of your plan’s network will usually lead to a loss of coverage for any items you buy.
Finding a Medicare-enrolled DME Supplier near you
To find a local Medicare supplier check this here at Medicare.gov
Durable Medical Equipment generally covered by Medicare if you qualify
If you don’t find the equipment you are looking for in my list of Medicare covered DME’s below, you can use this link to Mediace.gov
Alternating Pressure Pads and Mattresses
Audible/visible Signal Pacemaker Monitor
Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
Bed Side Rails
Bed Trapeze – covered if your loved one is confined to their bed and needs one to change position
Blood sugar monitors
Blood sugar (glucose) test strips
Canes (however, white canes for the blind aren’t covered)
Continuous passive motion (CPM) machines
Continuous Positive Pressure Airway Devices, Accessories and Therapy
Cushion Lift Power Seat
Digital Electronic Pacemaker
Electric Hospital beds
Gel Flotation Pads and Mattresses
Glucose Control Solutions
Infusion pumps and supplies (when necessary to administer certain drugs)
Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
Mobile Geriatric Chair
Nebulizers and some nebulizer medications (if reasonable and necessary)
Oxygen equipment and accessories
Patient lifts (a medical device used to lift you from a bed or wheelchair)
Postural Drainage Boards
Self-Contained Pacemaker Monitor
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
Urinals (autoclavable hospital type)
Whirlpool Bath Equipment – if your loved one is homebound and the pool is medically needed. If your loved one isn’t homebound Medicare will cover the cost of treatments in a hospital.
Prosthetic and Orthotic Items
Orthopedic shoes only when they’re a necessary part of a leg brace
Arm, leg, back, and neck braces (orthotics), as long as you go to a supplier that’s enrolled in Medicare
Artificial limbs and eyes
Breast prostheses (including a surgical bra) after a mastectomy
Ostomy bags and certain related supplies
Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.
DME’s usually not covered by Medicare
Augmentative Communication Device
Bed Exit Alarms
Bed Sensor Pads
Beds – Lounge
Blood Glucose Analyzers
Braille Teaching Texts
Caregiver Paging Systems
Catheters – except those which are used for permanent medical conditions where the catheter is considered as a prosthetic
Chair Exit Alarms
Chair Sensor Pads
Contact Lenses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens
Disposable Bed Protectors
Door Exit Alarms
Electrical Wound Stimulation
Exit Alarm Mat
Eye Glasses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens.
Heat and Massage Foam Cushion Pad
Heating and Cooling Plants
Humidifiers – not room humidifiers
Injectors (hypodermic jet pressure powered devices for Insulin injection)
Motion Sensor Exit Systems with Pagers
Over bed Tables
Paraffin Bath Units (if not Portable)
Portable Room Heaters
Portable Whirlpool Pumps
Preset Portable Oxygen Units
Pull String Alarms
Raised Toilet Seats
Special TV Close Caption
Speech Teaching Machines
Surgical Face Masks
Telephone Alert Systems
Television Assistive Listening Devices
Walk in Bathtubs
Get free assistance with understanding Medicare
If you would like help with Medicare you can get free help at SHIP – State Health Insurance Assistance Programs.
SHIP is a free state counseling service for people to talk to someone Who’ll help them understand Medicare, Medicare Advantage, Medigap and Medicaid benefits.
It is generally a phone service, but some programs may offer face-to-appointments as well.
To find local Medicare help click on this link here
How to contact a SHIP counselor in your state step by step
Step 2 –
Click on one of the two buttons to find your state – they both lead to the same menu to choose your state
Step 4 –
The screen will open a window with the contact info and a phone number for you to call in your state.
Will Medicaid cover bed wedges and bathroom safety equipment ?
Due to its funding structure – federal and state – Medicaid is quite different from Medicare.
Medicaid has basic national guidelines within which each state has to work, but there is a lot of leeway to develop programs, and to allocate funding to them.
As a result any state may have multiple programs where Medicaid has agreed to waive certain requirements for eligibility, in order that the state may provide care to those who need it, and who might otherwise have been missed or lost by the system, due to the fact they were otherwise not eligible.
These programs, known as waivers, have specific eligibility requirements, and typically have a limited number of places as the funding is limited too.
Waivers will vary greatly between the different states, but there are many specifically for caring for people in their homes, and in the community, aiming to help the participants maintain their independence.
And with so many different waivers across the US – literally hundreds – what is considered a DME is just as unpredictable and wide ranging.
Medicaid and state programs and waivers for in home care services
The programs, which have been designed to help individuals to live independently in their homes, can be called “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.
These programs were developed primarily for low income families, disabled individuals and the elderly with medical needs.
If you would like to read more comprehensive information on HCBS programs or waivers, you can find that at medicaid.gov –
The programs/waivers, that I have outlined, will pay for “home medical equipment” – DME’s
The term “home”, means that the participants can be living in –
- their own home
- their family home
- a group home
- an assisted living facility
- a custodial care facility
With certain programs and waivers there may be a broader interpretation of what qualifies as a DME
“Consumer Direction”or “Self Direction”
On an HCBS program, or waiver, with “Consumer Direction” or “Self Direction” as a way of managing the funding of the project, the program beneficiaries are alotted a budget to cover their needs. Each beneficiary is also appointed a financial advisor.
If it is apparent that the beneficiary of the program cannot get by without a certain piece of equipment, and it is within their budget, they will very often be able to purchase it.
Due to the fact that the goal here is to help the individuals to remain in their homes, the items bought can cover a much wider range than that which is available as DME under Medicare coverage, as long as they are needed medically and within budget.
To find out more about Medicaid Self Direction click here
Helping the elderly return to their homes
Money follows the person – is a Medicaid based program which assists elderly adults in regaining their independence by helping them make the transition from nursing facilities back into the community and their homes.
Assisted living is here also considered as an individuals own home.
What may be considered a DME is again very often different from that which is covered with Medicare, even remodeling parts of the home, if it is necessary for the participant can make the transition, is paid for by the program.
If you don’t quite qualify for Medicaid
Some states have a program called Spend Down.
Spend Down is a program which allows you to reduce your income so that you qualify for Medicaid Benefits.
The system is designed so that if you’re are not eligible for Medicaid benefits because you have too high a level of income, or assets, that you can reduce those, become eligible for Medicaid and other Medicaid HCBS’s and waivers.
One way this is done is to allow you to subtract your medical bills from your income, and if after that you fall below the Medicaid income limit, you will be eligible for Medicaid benefits.
What I written here is grossly simplified, but you can read more in this article on the US NEWs website here.
How do you get DME’s with Medicaid waivers and HBSC programs ?
– the doctor, or therapist, has to provide a medical justification letter, which states that the equipment is medically necessary
– you or your loved one have to find a DME supplier who is Medicaid-approved, and to give to them the medical justification letter
– the DME supplier then fills out a Prior Approval Application for Medicaid
– the document is then sent to the Medicaid State Office for approval or denial
– if you or your loved one are unsuccessful you will be notified as to the reasons why, and given advice on how to appeal the decision
– if approved you or your loved one will receive the DME
How to find the HCBS programs, waivers and 1915 waivers in your state
Click on the link below will it take you to CMS.gov (CENTER FOR MEDICARE AND MEDICAID SERVICES) to look at the different “HCBS programs”, “waivers” and “1915 waivers” offered by your state and Medicaid.
Once you select your state on the map, it will show you a section with your state waivers and programs, and also their criteria for eligibility- click here.
Step 1 – Find your state on the map.
Step 2 – Click on you state – I gave N.Dakota as an example
Step 3 – You will come to your state and it’s list of available resources, and here you can choose
- your state Medicaid Agency marked with a (1), or
- your Home and Community Based Services, Waivers and 1915 Waivers marked with a (2)
Below is an example of the type of page you will get if you click on the HCBS programs and waivers link.
You can find out what programs and waivers there are in your state, and what the criteria is for eligibility.
How to find your State Medicaid State Agency
Step 1 – Once you have clicked the link to Medicade.gov, look at the section I have outlined in the image below
Step 2 – select your state, and click on “GO” – it will take you to your State medicaid Agency.
Other financial assistance you or your loved one may be able to get for DME’s
Assistive Technology Projects
All states receive a national grant for “Assistive Technology Projects”.
The goal of the projects is to increase access to assistive devices in the home for those who are in need of them – the elderly being one of the primary focus groups.
“Assistive Technology” and “DME” are very much synonymous for these purposes.
You can find out about the programs in your state on the website at3.net
Select your state on the map or from the drop down menu and click on the button “Go to state”
– I chose Florida for this example
Look for the link “Program Title” – for my example I outlined it in red – and click on that.
The state AT Project website will come up, and you can sign up or use ther contact info to get in touch and find out what they offer to help the elderly, and if you or a loved one are eligible.
State Financial Assistance Programs
These non-Medicaid programs are designed for the elderly to remain living in their homes – not all states have them.
The programs will pay for many different safety items, medical equipment and even remodeling of the home to ensure that the elderly can continue to live there.
The programs are typically focused on the elderly and the disabled.
If you contact your local Agency on Aging, they should be able to help you find out abot programs in your state.
Protection and Advocacy Programs
Each state has legal services providing assistance to the elderly in disputing their denied claims.
You cannot get bed wedges covered by Original Medicare Part B for “use in the home” as Medicare doesn’t consider they are “medically necessary”.
With an item that Medicare Part B will cover, get your prescription from a Medicare-enrolled physician and don’t forget before purchasing to ask the supplier if they are a Participating Supplier who accepts “assignment”.
Even if Medicare won’t cover your bed wedges, check that you don’t qualify for Medicaid or one of the other non-Medicaid state funded programs.
If you spend a lot on Medical supplies, take a look at “Spend-Down”, and see if you can qualify for Medicaid.
Good luck !
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