Does Medicare cover toilet safety frames ?
If you, like me, are the caregiver to an elderly parent, or are concerned about them falling in the bathroom due to a lack of mobility, you may have considered purchasing a toilet safety frame. And like me, you may have wondered how you are going to pay for this, along with so many other thoroughly justified items for your parent’s safety.
Does Medicare cover toilet safety frames ? Original Medicare does not cover toilet safety frames, but Medicare Advantage plans may possibly do so, as well as Medicaid, Veterans Benefits, rural funding, state waivers and non-medicaid state financial assistance plans for the elderly, which can cover bathroom equipment for your elderly loved ones.
So, does Medicare cover any bathroom safety equipment ?
I should point out at this point, that although Medicare Part B will not cover a toilet safety frame, I did just say that among the equipment it will cover, if it is deemed “medically necessary” is a bedside commode.
One type of a bedside commode is a 3-in-1 commode, and luckily for us a 3-in-1 commode is so called as it can be used for three different functions –
- as a bedside commode
- as raised toilet seat
- and as a toilet safety frame
If you can get your doctor to certify that a bedside commode is “medically necessary”, or if you have had one already, you will be able to use it as a safety frame around your toilet as well.
How does Original Medicare judge what equipment is to be covered or not ?
The Medicare classification for medical equipment for use in the home is “Durable Medical Equipment” or DME’s.
Below there is a list of Durable Medical Equipment covered by Medicare. to jump straight to it you can click here.
If an item is to considered as “Durable Medical Equipment” it must meet the following criteria:
- Durable (must be able to withstand repeated use overtime)
- It can only be used for a medical reason, as opposed to just for comfort
- Not normally of use to someone who isn’t sick or injured
- You must have it for use in your home
- Should have an expected lifetime of at least 3 years
If your choice of equipment does not meet these basic criteria, you most likely won’t get coverage from Medicare part B.
In Literature published by Medicare they cite examples of Durable Medical Equipment as walkers, commode chairs, hospital beds and wheelchairs.
How does your loved one qualify for Medicare covered DME’s ?
To find a local Medicare supplier in your area try this link at Medicare.gov
For an item you need for use in you home to qualify as DME for Medicare coverage, you must –
- be enrolled in Medicare Part B
- have a prescription signed by your Medicare enrolled doctor saying that the equipment is a medically necessary
- purchase the DME’s from a Medicare-enrolled supplier
Care facilities – hospitals, or nursing homes, don’t qualify as a “home” for Medicare Part B, although a long-term care facility, such as assisted living can qualify as a “home” for Medicare part B.
Care facilities, as defined above, are covered under Medicare Part A (hospital treatment) and any DME needed when in a nursing facility for up to 100 days should be covered by the facility.
Original Medicare part B defines living at home as –
- living in your own home
- living in the family home
- living in the community, such as assisted living
What does your loved one do once they have a prescription for their equipment ?
Once Medicare Part B is agreed to your loved one’s purchase, they will pay for 80% of the Medicare-approved price of your loved one’s DME.
This leaves your loved one responsible for their Medicare co-payment which is equal to 20% of the Medicare-approved price of the DME, and only if they have used a Medicare-enrolled “participating” supplier who accepts assignment.
If not they may much more may be more – so read on !
Your loved one will also will also have to pay their annual deductible (if it hasn’t already been met)
For less expensive items, Medicare usually purchase them outright, and for more important purchases they will rent the items on a monthly basis from the supplier.
After a certain number of monthly rental payments your loved one’s item will be considered purchased from the supplier – this is part of the Medicare agreements with it’s approved suppliers.
If the equipment is rented from a Medicare-enrolled “participating” supplier who accepts assignment, your loved one will pay a monthly co-payment of 20% of the Medicare-approved rental price.
What mistakes does your loved one need to avoid with Medicare ?
To pay the least amount possible for any equipment your loved one has to use a Medicare enrolled “participating” supplier who accepts “assignment”.
This ensures the item is being purchased for the lowest possible price – the Medicare-approved price.
Why is this ?
Medicare-enrolled suppliers divide into two groups –
- Medicare Suppliers
- Medicare “Participating” Suppliers
Medicare “Participating” Suppliers have an agreement with Medicare to accept what is called “assignment” – they can only charge the Medicare-approved price for DME’s.
Non-participating suppliers have not come to this agreement with Medicare and can charge what they wish for DME’s.
What happens if I fail to get a “participating supplier” ?
A Medicare-enrolled supplier who is not a “Participating” supplier –
- will accept payment from Medicare for DME at the Medicare-approved price
- but will sell the DME at whatever price they choose
The result –
- Medicare pays the supplier their 80% of the Medicare-approved price for the equipment
- your loved one ends up paying their 20% c0-pay of the Medicare-approved price for the equipment + any difference between the Medicare-approved price, and the supplier’s price
- and your loved one will also have to pay their annual Medicare deductible if it applies
It plays out in real terms like this –
Medicare-approved toilet safety frame price – 100$
Medicare-enrolled Supplier toilet safety frame price -125$
- Medicare pay 80% 0f the Medicare-approve price = 80$
- Your loved one pays 20% co-pay of Medicare-approve price = 20$
- Your loved one then pays the difference between the Medicare-approved price, and the Medicare-enrolled Supplier price – 125$ – 100$ = 25$
- So, your loved one pays 20$ + 25$ = 45$
If your loved one’s Medicare-enrolled supplier had been a “participating” supplier who accepts assignment, they would have paid 25$ less.
Always use a Medicare-enrolled Participating Supplier and confirm that the supplier accepts “assignment”, and this way you get the best coverage and pay the least amount possible.
What happens with Medicare Advantage ?
As to the exact process, and which suppliers to use, your loved one must consult with their provider if they have a Medicare Advantage plan.
Your loved one will have to use the provider’s network suppliers, and if they don’t, they may find themselves paying the whole bill for their equipment.
Medicare Advantage Plans are offered by private companies contracted by Medicare to provide Medicare services, and they must by law, provide at least the same coverage and services, as Original Medicare Parts A and B. They may also provide more, and some may include bathroom safety equipment not covered by Medicare.
Like Original Medicare Parts A and B, Medicare Advantage plans usually have a co-pay. The rates of the co-pay will be specific to each plan and its provider.
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.
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.
Does Medicaid cover toilet safety frames ?
Funding for Medicaid programs is done both at a federal and a state level. A state may have any number of different Medicaid programs and waivers, and each with different eligibility guidelines, resulting in hundreds of programs for Medicaid throughout the US.
Medicaid in skilled nursing facilities and hospitals
In hospitals and skilled nursing facilities the job of ordering the equipment needed for your loved ones will be handled by the facility.
Medicaid and state programs for in the home
Medicaid programs which are for outside of skilled nursing facilities go under the labels of “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.
The programs and waivers are there to help the participants to maintain their independence in their own homes.
A comprehensive explanation of HCBS programs and waivers with more technical information is available at this link to medicaid.gov –
The programs and waivers for the home, like Medicare, pay for “home medical equipment”, but unlike Medicare, will often cover 100% of the cost of the equipment.
For “Waivers” and HCBS, the term “home” is used to mean that the beneficiary must be living in –
- their own home
- their family home
- a group home
- an assisted living facility
- a custodial care facility
DME’s for the home may be easier to get with some Medicaid waivers than with others
Certain HCBS programs and waivers allow for what is called Consumer Direction/ Self Direction.
A participant in a program which has consumer, or self direction, will have an allotted budget to cover their needs, and to help them maintain their independence. The participant has a financial planner appointed to them to help manage the funds to meet their needs.
If DME’s help them to maintain their independence in their home they are considered as part of their needs.
Equipment not covered by Medicare such as toilet safety frames, bathtub lifts, grab bars, if judged medically necessary, and within the person’s allotted budget, can be purchased on some of these programs or waivers.
To find out more about Medicaid Self Direction click here
Programs devised to transition people back from care institutions into their own homes
Money follows the person is a Medicaid program which relocates the elderly back to their homes – which, as I said previously, can also mean assisted living – after they have been nursing facilities.
If particular equipment is required so that the participant may relocate home, the program will purchase the equipment for them.
The range of equipment considered as DME’s is again much less restricted than under Medicare.
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 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.
What is the path to acquiring DME’s with Medicaid waivers and HBSC programs ?
– the doctor, or therapist, must provide a medical justification letter, which states that the equipment desired is medically necessary.
– find DME supplier, one who is Medicaid approved, and pass on to them the medical justification letter from the doctor, or therapist.
– the DME supplier should then fill out a Prior Approval Application for Medicaid
– the document goes to the Medicaid State Office for approval or denial
– if unsuccessful, your loved one will be notified as to the reasons why, and told how to appeal the decision
– if approved you 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.
How to get a toilet safety frame covered as a Veteran ?
For veterans, the Department of Veterans’ Affairs has grants, programs, financial assistance and pensions which can help to cover the cost of DME’s.
To find out about your loved one’s local VA Medical Centers, Clinics and offices click this link here.
Here are some of the forms of assistance available if your loved one is a veteran.
- Grants for remodeling homes due to disabilities inflicted during military service
- Veterans Direct HBCS – works like self direction
- Veterans Pensions – certain pensions allow for the purchase of medical equipment that veterans need for their homes, and the money is not lost to the pensioner
The range of DME’s is far wider than that available under Medicare.
Other funding your loved one can get for a toilet safety frame
Assistive Technology Projects
These projects exist to increase access to assistive devices in the home.
The elderly are one of the primary groups who are meant to benefit form these projects.
The terms “Assistive Technology” and “DME” are basically interchangeable, and all manner of equipment which can help in the home is covered.
Select you 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 are non-Medicaid programs to reduce the number of elderly persons entering into the Medicaid run nursing homes.
The programs are run an a state-by-state basis, and are designed to help the elderly to remain living independently in their own homes. Not all the states have one.
The programs are destined for the elderly and disabled, but eligibility differs with each program.
The programs will modify homes and purchase any necessary medical and safety equipment.
USDA Rural development Section 504 Home Repair program
In rural areas the elderly may obtain a grant for home remodeling and safety equipment –
“repair, improve or modernize their homes or grants to elderly very-low-income homeowners to remove health and safety hazards.” – source USDA.GOV
- To qualify you must
- be the owner of the property
- be 62 yrs and over
- have a family income of less than 50% of the local average
- be unable to repay a home repair loan
Applications are accepted year round at your local Rural Development office here
To talk to a local USDA Home loan specialist for advice here
Protection and Advocacy Programs
Providing the elderly with legal assistance in disputing denied claims.
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