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 discovered 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.
Medicare Part B does not cover bed wedges as they don’t consider them to be “medically necessary”. Other programs, such as Medicaid, non-Medicaid State Financial Assistance Programs and Assistive Technology Projects, may help with bed wedges, if you are eligible.
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 “10 Great Alternatives To Bed Rails For The Elderly”, outlining the dangers of bed rails for certain individuals who are at risk if they use them, and discussing the safer alternatives, amongst which are bed wedges.
You can read my article here
Contents Overview & Quicklinks
Does Medicare cover bathroom equipment ?
How often does Medicare pay for a walker, or any other type of equipment it covers ?
Will Medicare pay for a walker and a wheelchair ?
Does Medicare cover exercise equipment ?
What happens if my DME is damaged, lost or stolen ?
What equipment does Medicare cover ?
How do you qualify for Medicare coverage ?
What do you do with your signed prescription for your DME ?
What coverage do you get with Medicare Advantage Plans ?
Finding a Medicare-enrolled DME Supplier near me ?
Durable Medical Equipment generally covered by Medicare if you qualify
DME, usually not covered by Medicare
Get free assistance with understanding Medicare
Does Medicaid cover bed wedges ?
On certain programs and waivers, there may be a broader interpretation of what is covered as DME
How to find the HCBS programs, waivers and 1915 waivers in your state ?
How to get your DME with Medicaid and state waivers and HCBS programs ?
If you don’t quite qualify for Medicaid ?
Other state financial assistance, you and your loved one may be able to get for DME
You are going to discover, if you are your loved one’s 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
Does Medicare cover bathroom 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 Part B 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 (only if it’s waterproof).
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 will only pay the 20% Medicare co-payment and your deductible if you have not yet met that for the year.
Some Medicare Advantage Plans may cover some bathroom equipment if the beneficiary is suffering from certain chronic illnesses. You can check this out below in the Medicare Advantage section 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.
Will Medicare pay for a 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 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 equipment does Medicare cover ?
The type of equipment which Medicare Part B will cover is called durable medical equipment when it is prescribed as “medically necessary”.
Durable medical equipment is equipment which can withstand repeated use over a sustained period of time.
Original Medicare part B covers Durable Medical Equipment, or DME’s “for use in the home”.
Typical items of durable medical equipment which Medicare Part B covers –
- wheelchairs
- walkers
- crutches
- bed trapeze bars
- bedside commodes
- patient lifts
For items covered, there are very specific guidelines about the qualifying diagnoses for each piece of equipment.
Medicare does not cover disposable equipment and supplies such as –
- gloves
- fabric dressings
- band aids
- gauze disposable face masks
Some disposable supplies may be covered if you have the Medicare Home Health Care Benefit, or if they are being used in conjunction with a specific item of durable medical equipment which you have been prescribed and received coverage for.
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 Medicare, an item of durable medical equipment has to fill 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 “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 only pay your Medicare 20% co-payment of the Medicare-approved price for your equipment, plus your deductible if it applies, as long as you’ve 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
Some items, typically 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, supplies and equipment that Medicare Parts A and B cover, and sometimes a few extra services.
In 2019 the Centers for Medicare & Medicaid announced an expansion of the coverage of Medicare Advantage –
Beginning in 2019, Medicare Advantage plans can now offer supplemental benefits that are not covered under Medicare Parts A or B, if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.
The text source – “CMS finalizes Medicare Advantage and Part D payment and policy updates to maximize competition and coverage” April 1, 2019. You can read the text here.
Benefits for chronic conditions, which can cover items such as air conditioners, bathroom safety for individuals with mobility conditions, and even trips to the grocery store for food shopping, are now allowed.
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 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 Medicare.gov
Air-Fluidized Bed
Alternating Pressure Pads and Mattresses
Audible/visible Signal Pacemaker Monitor
Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
Bead Bed
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)
Commode chairs
Continuous passive motion (CPM) machines
Continuous Positive Pressure Airway Devices, Accessories and Therapy
Crutches
Cushion Lift Power Seat
Defibrillators
Diabetic Strips
Digital Electronic Pacemaker
Electric Hospital beds
Gel Flotation Pads and Mattresses
Glucose Control Solutions
Heat Lamps
Hospital beds
Hydraulic Lift
Infusion pumps and supplies (when necessary to administer certain drugs)
IPPB Machines
Iron Lung
Lymphedema Pumps
Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
Mattress
Medical Oxygen
Mobile Geriatric Chair
Motorized Wheelchairs
Muscle Stimulators
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)
Oxygen Tents
Patient Lifts
Percussors
Postural Drainage Boards
Quad-Canes
Respirators
Rolling Chairs
Safety Roller
Seat Lift
Self-Contained Pacemaker Monitor
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
Sitz Bath
Steam Packs
Suction pumps
Traction equipment
Ultraviolet Cabinet
Urinals (autoclavable hospital type)
Vaporizers
Ventilators
Walkers
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
Urological supplies
Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.
DME usually not covered by Medicare
Adult Diapers
Air Cleaners
Air Conditioners
Alcohol Swabs
Augmentative Communication Device
Bathroom Aids
Bathtub Lifts
Bathtub Seats
Bed Bath
Bed Boards
Bed Exit Alarms
Bed Sensor Pads
Bed Lifter
Beds – Lounge
Bed Wedges
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
Communicator
Contact Lenses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens
Dehumidifiers
Dentures
Diathermy Machines
Disposable Bed Protectors
Disposable Sheets
Door Exit Alarms
Easygrip Scissors
Elastic Stockings
Electrical Wound Stimulation
Electrostatic Machines
Elevators
Emesis Basins
Esophageal Dilators
Exercise Machines
Exit Alarm Mat
Eye Glasses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens.
Fall Alarms
Fans
Fabric Supports
Fomentation Device
Grab Bars
Grabbers
Gauze
Hearing Aids
Heat and Massage Foam Cushion Pad
Heating and Cooling Plants
Home Modifications
Humidifiers – not room humidifiers
Incontinence Pads
Injectors (hypodermic jet pressure powered devices for Insulin injection)
Irrigating Kits
Insulin Pens
Massage Equipment
Motion Sensors
Motion Sensor Exit Systems with Pagers
Needles
Oscillating Beds
Over bed Tables
Paraffin Bath Units (if not Portable)
Parallel Bars
Portable Room Heaters
Portable Whirlpool Pumps
Preset Portable Oxygen Units
Pressure Leotards
Pressure Stockings
Pulse Tachometer
Pull String Alarms
Raised Toilet Seats
Ramps
Reading Machines
Reflectance Colorimeters
Sauna Baths
Special TV Close Caption
Speech Teaching Machines
Stair Lifts
Standing Table
Support Hose
Surgical Face Masks
Surgical Leggings
Syringes
Telephone Alert Systems
Television Assistive Listening Devices
Telephone Arms
Toilet Seats
Treadmill Exercisers
Walk in Bathtubs
Wheelchair Lifts
Whirlpool Pumps
White Canes
Wigs
Get free assistance with understanding Medicare
SHIP – State Health Insurance Assistance Programs –
If you need help with your coverage and benefits youcan get free guidance about Medicare, Medicaid and Medigap from your state program.
I have written a short guide explaining how to find your local SHIP and you can find that here – “Free Help Understanding Medicare And Medicaid ? Here’s Where You Get It”.
Will Medicaid cover bed wedges ?
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 for 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 –
https://www.medicaid.gov/medicaid/hcbs/authorities/index.html
The programs/waivers, that I have outlined, will pay for “home medical equipment” – DME
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
On certain programs and waivers, there may be a broader interpretation of what is covered 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 allotted 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 individual’s 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 to make the transition, is paid for by the program.
How to find the HCBS programs, waivers and 1915 waivers in your state
I have an article with a list of the HCBS Waivers, 1915 Waivers, HCBS Programs and the Money Follows The Person Programs for seniors which are available in each state, along with links to the different program websites. Also listed are all the PACE Programs – Programs of All-inclusive Care for the Elderly -for care in the home – “Medicaid Home and Community Based Services Waivers and Programs For Seniors Listed By State”.
How do you get DME with Medicaid waivers and HCBS programs ?
Step 1
– the doctor, or therapist, has to provide a medical justification letter, which states that the equipment is medically necessary
Step 2
– you or your loved one have to find a DME supplier who is Medicaid-approved, and to give to them the medical justification letter
Step 3
– the DME supplier then fills out a Prior Approval Application for Medicaid
Step 4
– the document is then sent to the Medicaid State Office for approval or denial
Step 5
– 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
Step 6
– if approved, you or your loved one will receive the DME
If you don’t quite qualify for Medicaid
Spend Down Programs
“Spending Down” is a method devised by Medicaid to help to reduce a person’s income, or income + asset level so that they may become eligible for Medicaid.
On Spend Down Programs certain expenses and other, may be deducted from the participants’ income in order that they qualify for coverage.
There are two types of Spend Down –
- Income Spend Down
- Asset Spend Down
You can find out much more about Spend Down in a post here – “What is Spend Down ?”
How to find your State Medicaid State Agency
If all the technical jargon was too much for you, I would contact your state Medicaid Agency, and you can do that here.
Step 1 – Once you have clicked the link to Medicaid.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.
State financial assistance you or your loved one may be able to get for DME
Assistive Technology Programs
All states receive a national grant for “Assistive Technology Programs”.
The goal of the programs 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
To check out what programs are running in your state, click here.
Step 1/
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
Step 2/
Look for the link “Program Title” – for my example I outlined it in red – and click on that.
Step 3/
The State AT Program website will come up, and you can sign up or use their 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 Area Agency on Aging, they should be able to help you find out about programs in your state.
Protection and Advocacy Programs
Each state has legal services providing assistance to the elderly in disputing their denied claims.
Summary
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 !
I’m Gareth, the author and owner of Looking After Mom and Dad.com
I have been a caregiver for over 10 yrs and share all my tips here.
