Does Medicare Cover Exercise Equipment ?
Everyday I help my mom go through her little routine of exercises to keep her back strong, and to make sure her hip replacement doesn’t do anything it shouldn’t.
Staying healthy is going to be the number priority for all of our elderly loved ones. There are lots of ways of doing this from eating well, to joining exercise groups and buying home exercise equipment. It all comes at a financial cost and we are left looking for ways to pay.
Does Medicare cover exercise equipment ? Original Medicare Part B does not cover exercise equipment, but it does cover physical and occupational therapy treatments. Medicare Advantage plans sometimes have coverage for exercise programs. You may be able to get funding for exercise equipment from Medicaid and other state funding sources.
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 as with equipment you will need to make sure that therapists 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.
For those of you who have been a caregiver for a while, it won’t be a surprise to discover that if a piece of equipment is not “medically necessary”, Medicare will not cover it.
I am going to take a look at some medical and safety equipment to broadly outline –
- what Medicare will and won’t typically cover
- how to get Medicare coverage when it is available
- how to not make mistakes with Medicare
- how to get free Medicare guidance in your state with a counselor
Durable Medical Equipment – what is that ?
Original Medicare has named the medical equipment that it is willing to cover Durable Medical Equipment.
Durable Medical Equipment which is “for use in the home” is covered by Original Medicare Part B.
Medical equipment used in skilled nursing facilities, including DME for short term stays, is covered by Original Medicare Part A (hospital care).
For equipment to get onto the Medicare Durable Medical Equipment list it must fulfill following criteria –
- it must hold up to sustained use over a long period of time – durable
- it can only be used for medical reasons – not for comfort
- it’s got to be useful to person who is sick, and hardly of use to a person who is not
- it must be used primarily in the home
- it must be expected to function properly for a minimum of 3 years
Will Medicare cover your bathroom safety equipment ?
The bathroom, is going to be the room with probably the most associated risks, and probably it has one of the larger varieties of safety equipment available to it.
Sadly, Medicare is not not going to help much.
It will not cover what it considers to be comfort items, and that includes all of the following –
- grab bars
- raised toilet seats
- bath lifts
- shower chairs
- bath chairs
- transfer seats
- toilet safety frames
Original Medicare Part B will though typically cover crutches, walkers and bedside commodes, if they are “medically necessary” and prescribed by a Medicare-enrolled physician and these pieces of equipment can help in the bathroom to reduce the risk of falling, and to lend stability to those who have mobility and strength issues.
I have a long article, with 50 plus safety tips, that I have learned over the 11 years that I have looked after my mom and dad. These are both practical tips, and some suggestions for equipment you may find helpful. You can read the article here.
If you are looking for suggestions and advice on how to make bathing easier for your parent, especially if you are assisting them, then I have another article discussing ways I have found useful to make it a more comfortable and dignified experience for all parties – that one is here.
How often does Medicare pay for a walker, or DME ?
Original Medicare Part B will replace DME that you rent, or own, if it’s –
- worn out through use
- been in your possession for its entire lifetime
- it must be so worn out that it can’t be fixed
- five years is the minimum period considered to be a lifetime for an item
- the lifetime can vary depending on the type of equipment
In the case of a walker which is worn, Medicare Part B will typically replace it every five years, so long as it has always been in your possession, and it is beyond repair.
If an item is worn out prior to the end of it considered lifetime, Medicare will pay to repair it, that is unless the repair is more costly than a replacement item.
If you need to replace a worn out item you will have to go through the process of getting a prescription from a Medicare-enrolled doctor stating that your walker is medically necessary.
The process is pretty much the same for all replacement items, apart form those which require prior approval.
How do you qualify for Medicare coverage and get your DME ?
To be able to qualify for Medicare coverage of DME’s “for use in the home” under Original medicare Part B, you –
- must be enrolled in Medicare Part B
- must get a signed prescription from your Medicare-enrolled doctor stating that your item is “medically necessary”
- need to be purchasing the equipment through 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
So now you have a prescription from a Medicare-enrolled doctor, what do you do ?
Armed with your prescription for your equipment, you –
- find and visit a Medicare-enrolled DME supplier
- always use a Medicare-enrolled supplier
- for the best possible coverage form Medicare Part B you must make sure that the supplier is a Medicare-enrolled “participating” supplier who accepts “assignment’
- Medicare gives coverage to only the basic models of any equipment, so the range of equipment your prescription will purchase won’t be that large
- for certain equipment you may be allowed to upgrade you, but you will pay the difference between the price of the Medicare-approved model and the upgrade, and it isn’t always possible
- choose the model you like from the range of equipment that you have been prescribed
- it’s time to do any necessary paperwork for Medicare and for the supplier
Medicare part B, typically provides cover for 80% of the Medicare-approved price for DME, because you have a prescription from a Medicare-approved doctor, and because you purchased your item from a Medicare-enrolled supplier.
If you use a Medicare-enrolled “participating” supplier who accepts assignment, you will then, typically pay your Medicare 20% co-payment of the Medicare-approved price for your equipment, plus your deductible if it applies.
Always use, a Medicare-enrolled “participating” supplier who accepts assignment, if you don’t you may have to pay a lot more.
Will Medicare purchase or rent my DME
Medicare both rents and buys equipment outright.
The smaller items are usually purchased and the more important pieces, such as hospital beds are rented.
If your item is rented from a Medicare-enrolled “participating” supplier who accepts assignment, you will typically pay a monthly 20% co-payment of the Medicare-approved rental price for the it, and also, if it applies your deductible.
Locate a Medicare-enrolled DME Supplier near you
To find a local Medicare supplier check this here at Medicare.gov
Do Medicare Advantage Plans cover exercise equipment ?
In a Medicare Advantage Plan you are covered for at least the same medical services, supplies and equipment that Medicare Parts A and B cover, and sometimes a few extra services, and this can be exercise programs or gym memberships with certain Advantage plans.
So, generally an Advantage plan will not cover your exercise equipment, but they may cover an exercise program, or gym membership.
You need to contact your Advantage plan provider to find out.
If you are trying to get coverage for any medical equipment which is covered by Medicare, don’t forget that you have to go through your Advantage plan provider’s network, their exact process for buying equipment with coverage, the doctors they work with and their supply network.
Using doctors and suppliers outside of your plans network will likely lead to a loss of coverage.
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 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 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 and who’ll help them to understand Medicare, Medicare Advantage, Medigap and Medicaid benefits.
It’s generally a phone service, but some programs may offer face-to-face 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 bathroom safety equipment ?
The funding of Medicaid has a rather different structure to that of Medicare – it is funded both on a federal level and a state level.
Medicaid provides guidelines within which the states operate their Medicaid system, but with a lot of room to change things, as each state is putting their own funding in as well.
In each state Medicaid will agree to waive some of the requirements for eligibility for different programs, allowing the state to provide care to those who might otherwise have been missed, or lost, by the system.
In such cases, which are many across all the states, programs are known as waivers and each will have specific eligibility requirements, and generally a limited number of places.
Even though the waivers may vary greatly, there are waivers in all states which are specifically to help with care in the home for the elderly and the disabled.
With all these extra programs and waivers across the US, there is a great deal more flexibility and variety as to what can be considered DME, by comparison with Medicare.
Medicaid and state programs and waivers for in home care services
“Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers” are names of the services, and programs, offered to care for individuals in their homes and the community.
The primary focus of these programs is low income families, disabled individuals and the elderly with medical needs.
To read more about HCBS programs, waivers, or 1915 waivers, you can go to Medicaid itself at medicaid.gov –
HCBS programs, waivers, and 1915 waivers will all pay for the participants to have “home medical equipment” – DME.
The term “home” for the participants can be interpreted to mean –
- 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, which uses “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 do 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 go far beyond what is allowed as DME under Medicare coverage, so 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 to 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.
If you’re are not eligible for Medicaid benefits because your income level is too elevated, or your assets, the Spend-Down program helps you to reduce those, and to become eligible for Medicaid and HCBS’s and waivers.
One method used to do this, is to allow you to subtract your medical expenses from your income, and if subsequently you fall below the Medicaid income limit, you will be eligible to receive Medicaid benefits.
What I have 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 HCBS programs ?
– get a medical justification letter from your doctor, or therapist, which states that the equipment is medically necessary
– find a Medicaid-approved DME supplier and give to them the medical justification letter
– the DME supplier should fill out a Prior Approval Application for Medicaid
– the application is then sent to the Medicaid State Office
– if your application is unsuccessful you will be notified as to the reasons why, and given advice on how to appeal the decision
– if approved you will receive the DME you applied for
How to find the HCBS programs, waivers and 1915 waivers in your state
If you click on the link below it will 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.
State Funding Assistance
Assistive Technology Programs
Every state has Assistive Technology Programs which serve to increase access to assistive devices in the home for those who need them – the primary focus of the programs is on the elderly and the disabled.
Assistive Technology devices can include DME, and any other equipment which makes it possible for a person to complete tasks they otherwise cannot – this can be from jar openers for arthritic hands, through to electronic digital devices.
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 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
A number states have non-Medicaid financial assistance programs which provide funds for the elderly to remain living in their homes.
The programs pay with grants, give loans, or will do a combination of both for participants to buy different safety items, assistive equipment, and to pay for the costs of remodeling bathrooms, wheelchair ramps, kitchen modifications – all with the aim of keeping them from unnecessarily being institutionalized.
The programs primarily focus on the elderly and the disabled.
Your local Area Agency on Aging should be able to help you locate the programs and to see if you, or a loved one, are eligible to participate.
You cannot get exercise equipment covered by Original Medicare Part B for “use in the home”, as Medicare doesn’t consider it to be “medically necessary”.
For any DME which Medicare Part B will cover, make sure you get your prescription from a Medicare-enrolled doctor, and only purchase, or rent, from a supplier if they are a Participating Supplier who accepts “assignment”.
Even if Medicare won’t cover exercise equipment, look to see if you qualify for Medicaid, a Spend-down program, or any of the other non-Medicaid state funded programs – you can always check these things with your local Area Agency on Aging.
If you have a Medicare Advantage plan, ask your provider if they cover exercise programs or gym memberships.
Good luck !
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