Will Medicare Pay For An Adjustable Bed ?

by | Beginners Info, Health Care

One of the largest, and most costly items, that seniors may need to consider purchasing to maintain their independence in their home is an adjustable bed, so finding out how to pay for one is important.

Does Medicare cover adjustable beds ?  Yes, Original Medicare Part B will cover some adjustable beds – a basic hospital bed.  You will though, have to follow a strict process to get them covered, and they will only cover certain types from certain suppliers, and only 80% of the cost. 

In its literature Medicare defines Durable Medical Equipment as “ reusable medical equipment like, walkers, wheelchairs, or hospital beds” 

Durable medical Equipment is the name of the category of medical equipment that Medicare will cover.

Original Medicare will not provide cover for  just any adjustable bed, but will pay for a basic hospital bed, which is not fully electric. You can though pay the difference out of your own pocket to get a fully electronic bed.

Medicare negotiates with suppliers to obtain a certain price for certain beds, and those are the models which are going to be covered by Medicare.

For this reason it’s important to stick to the correct procedure if you want to be covered.

What are Medicare’s qualifying guidelines for a hospital bed ?

Original Medicare Part B will partially cover a hospital bed for use in the home if you meet one or more of the following criteria:

  • If you have a medical condition “which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or”
  • You require “positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or”
  • You require “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. Pillows or wedges must have been considered and ruled out, or”
  • You require “traction equipment which can only be attached to a hospital bed.”

 

Variable Height Hospital Beds – beds that allow the height of the bed to vary can be covered if you have met one or more of the principal criteria above, and require “a bed height different than a fixed height hospital bed to permit transfer to chair,  wheelchair or standing position.”

Semi-electric Hospital Beds  – can be covered if you have met one or more of the principal criteria above, and require “frequent changes in body position and/or has an immediate need for a change in body position.”

Heavy Duty Extra Wide Hospital Beds – can be covered if you have met one or more of the principal criteria above, and your “weight is more than 350 pounds but does not exceed 600 pounds.”

Extra Heavy Duty Hospital Beds – can be covered if you have met one or more of the principal criteria above, and your “weight is more than 600 pounds”

Total Electric Beds are not covered as they are deemed by Medicare to be a convenience feature, and they are “denied as not reasonable and necessary.”

 

The guidelines are from the CMS (Centers for Medicare and Medicaid Services) Requirements list for Hospital Beds and Accessories.

There is a much more technical document which you can read on CMS.gov – National Coverage Determination (NCD) for Hospital Beds (280.7)here.

What type of equipment does Medicare cover ?

Medicare will cover equipment for use in the home if it falls under it’s category of “durable medical equipment” or DME.

If you wish to skip ahead to the list of Durable Medical Equipment covered by Medicare click  here.

For equipment to be considered in the DME category by Medicare it must fill the following criteria :-

  • be “durable” and able to withstand constant use over an sustained length of time
  • the user has to be using the item for a medical reason, and not for comfort
  • it shouldn’t normally be useful to a person who is not or injured
  • the equipment is intended for use in the home – you are allowed to use it outside, but you have to be getting it because you can’t get on without it inside
  • it should have a lifetime lifetime of at least 3 years

Original Medicare will cover items like wheelchairs, crutches and walkers as it sees them as medically necessary.

But Original Medicare won’t cover what it considers comfort items, such as bathroom safety equipment like grab bars, shower chairs and raised toilet seats.

Medicare will, generally, only agree to the purchase of the most basic versions of the different items that they cover.

So, should you wish for anything more elaborate than the model of the DME covered by Medicare, you will have to pay for the upgrade yourself – which is not always possible.

How often can you get an adjustable bed with Medicare ?

If you have had a DME in your possession for its whole lifetime, which is worn outMedicare will replace it.

For equipment replacement, the lifetime of a DME cannot be less than 5 years. The equipment must be worn out from use to replace it.

Medicare only replaces like for like – you can’t get an item upgraded.

What happens if a DME is damaged or stolen?

If any DME covered by Medicare is lost, stolen, or damaged in an accident or a natural disaster, so badly that it can’t be repaired, Medicare will, as long as you have proof, replace it.

To locate a Medicare-enrolled supplier you can use this link to Medicare.gov

You can check Medicare’s documentation on DME’s here – Mediace.gov 

What’s the procedure for getting an adjustable/hospital bed with Medicare coverage ?

To get a hospital bed for home use covered through Medicare Part B you will need to –

  • be enrolled in Medicare Part B
  • have a prescription/order signed by your Medicare-enrolled doctor, or treating practitioner, which states that it’s a medical necessity to have the bed
  • be buying the bed from a Medicare-enrolled enrolled supplier

Should the Doctor, treating practitioner, or DME suppliers not be Medicare-enrolled, Medicare will not cover the purchase at all.

If you are claiming a hospital bed for your “home”, a hospital or nursing home  does not qualify for coverage under Medicare Part B.

Skilled nursing facilities qualify under Medicare Part A (hospital insurance).

For someone living in a long-term care facility, such as an assisted living, it can qualify as “home” for under Medicare Part B. 

The following can be considered living at “home” according to Medicare –

  • you can be in your own home
  • you can be living in the family home
  • you can be living in the community, such as assisted living

What do you do once you have the order/prescription ?

After you have got a prescription order filled out by your doctor, or treating practitioner, stating that your DME is medically necessary, you can go and choose your equipment from a Medicare-enrolled supplier.

If  it’s the case that you used a Medicare-enrolled doctor, and the supplier also is a Medicare-enrolled supplier then Medicare should accept to cover the purchase  and –

  • your deductible for Medicare part B will apply
  • you will need to pay the supplier your co-pay of 20% of the Medicare-approved price of the item 
  • Medicare will then pay the supplier the remaining 80% of the Medicare-approved price for your item

In the case of cheaper items Medicare will usually purchase the items.

With a hospital bed Medicare will most likely want to rent the bed on a monthly basis, the rental price being a Medicare-approved price, and you will pay the supplier your 20% co-pay of the monthly rental, plus you will have to pay your Medicare Part B annual deductible if it applies.

Why you should always use a Medicare-enrolled “participating” supplier 

If you use a supplier who is  not a Medicare-enrolled “participating” supplier you may pay more than if you had.

Why is it less expensive with a Medicare-enrolled “participating” supplier ?

Firstly, to get any kind of cover from Medicare you have to use a Medicare-enrolled supplier.
A Medicare-enrolled supplier has passed all of Medicare’s required standards of service and has agreed to take payment from Medicare.

But more importantly than that …

Medicare-enrolled suppliers are divided into two types –

  • Medicare Suppliers
  • Medicare “Participating” Suppliers

And Medicare “Participating” Suppliers have agreed with Medicare to accept what is known as “assignment” – most importantly,  a supplier who accepts “assignment” can only charge the Medicare-approved price for DME.

As a result –

  • the “participating” supplier will provide the documentation for your equipment for Medicare
  • if your equipment claim is approved by Medicare, the “participating”supplier can then only ask for the 20% co-pay of the Medicare-approved price
  • if your annual Medicare deductible applies you will have to pay this as well 

If you don’t use a “Participating” Supplier what’s the result ?

A Medicare-enrolled supplier who is not a “Participating” Supplier –

  • has agreed with Medicare to accept from them the payment for DME at the Medicare-approved price
  • but can sell the DME to you, the buyer, at up to 15% more than the Medicare approved price

What this means –

  • as agreed when your claim for a DME is submitted, if it is approved, Medicare will pay the supplier their 80% of the Medicare-approved price for your DME
  • and you end up paying your 20% co-pay of the Medicare-approved price for your item + the difference between the Medicare-approved price and the price the supplier is selling the item at to you (with a limit of 15% extra)
  • And you will have to pay your annual Medicare deductible if if it applies

Some states such as New York restrict the supplier from charging a full 15% above the Medicare-approved price. In New York they may only add 5%.

So do use a Medicare-enrolled “Participating” Supplier, and always ask if the supplier accepts “assignment”, as you can save a lot of money, particularly with an item as costly as a hospital bed. Don’t get burned !

What if you are being treated in a skilled nursing facility ?

If you’re being treated in a Skilled Nursing Facility or hospital, you will be covered by Medicare Part A (Hospital Insurance). The nursing facility under Medicare is required to provide any DME needed for 100 days.

Can you get a hospital/adjustable bed if you have a Medicare Advantage Plan ?

If you have a Medicare Advantage Plan (often called Medicare Part C) you should be able to get a bed covered by the plan if it is considered “medically necessary” by Medicare, but you must consult with your plan provider.

Medicare Advantage Plans are run by private companies, which are contracted by Medicare to provide Medicare services, and are bound by law to provide, at least, the same coverage as Original Medicare Parts A and B.

The companies providing these plans will have their own requirements for a claim.

Almost certainly, you will have to use a DME supplier in their network, otherwise you really are risking having to pay the whole bill for the bed yourself.

This is the list of durable medical equipment which is typically covered by Medicare

To qualify you will need to have Original Medicare Parts A and B.

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.

Corrective Lenses

Prosthetic Lenses
Cataract glasses (for Aphakia or absence of the lens of the eye)
Conventional glasses or contact lenses after surgery with insertion of an intraocular lens
Intraocular lenses

Important: Only standard frames are covered. Medicare will only pay for contact lenses or eyeglasses provided by a supplier enrolled in Medicare, no matter who submits the claim (you or your supplier).

And these are the DME’s typically 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

If you are trying to qualify for an adjustable bed through Medicare because you wanted a bed with side rails, you may be interested to know that they are not the safest option for certain categories of elderly, or frail individuals, and have been linked to many deaths.

In the article “Alternative to bed rails for the elderly” I outline lots of safer options to stop your parents from falling out of bed, and which are also far less costly than a hospital bed. It is worth a look, and you can find that here.

Free assistance with understanding Medicare

SHIP – State Health Insurance Assistance Programs –

Your SHIP offers guidance and advice on Medicare.

This is usually a phone service, but some programs will offer face-to-face appointments as well.

You may also get advice on Medicare Advantage, Medigap and Medicaid benefits.

To find your local SHIP click on this link  here

How to contact a SHIP counselor in your state, step by step

Step 1 –

After you have clicked on the link you will arrive here –

Step 2 –

Click on one of the two buttons to find your state 

Step 3 –

Pick your state and click on it.

Step 4 –

A window will open with the contact info and a phone number for you to call in your state.

If you don’t have Medicare, will Medicaid cover adjustable beds ?

Medicaid doesn’t operate in the same way as Medicare, as it is  joint federal and state funded. Each state runs its Medicaid program as it wishes, within the guidelines set out by the government, and this leads to there being differences from state to state as to what can be covered by Medicaid.

A state will have a Medicaid State Plan, and usually Home Community Based Services (HCBS), or waivers (also Medicaid), each with their own eligibility, criteria and goals, and resulting in hundreds of programs and waivers for Medicaid across the US.

With these hundreds of HCBS waivers and state plans, what can be considered durable medical equipment can vary from program to program, let alone from state to state.

Medicaid and state programs for in the home

Medicaid for home care, is called “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.

The HCBS programs, or waivers, operate to help the recipients to maintain their independence in their own home, by providing the care and services required to these ends, and by paying for “home medical equipment”.

If you would like to find more technical, and in depth information, about the different waivers which exist, take a look at the official Medicaid site –
https://www.medicaid.gov/medicaid/hcbs/authorities/index.html

The term “HOME” for HCBS programs and waivers, is used to mean that the beneficiary of a program, or waiver, must be living in –

  • their own home
  • their family home
  • a group home
  • an assisted living facility
  • a custodial care facility

Some Medicaid waivers will allow for more latitude with regards to what DME purchases may be covered for the home

Some HCBS programs, or waivers, allow for what is called Consumer Direction/ Self Direction.

The program participant is allotted funding, or a budget, for their living needs in their home, which they spend with the help of a financial planner. Durable medical equipment can be purchased with this budget if it is part of what they need.

Equipment such as a bathtub, grab bars, a bath lift, or a shower chair, which isn’t considered durable medical equipment by Medicare, if it is considered “medically necessary” and is within the allotted budget, may be purchased by participants on some of these programs, or waivers.

To find out more about Medicaid Self Direction click here

There are also programs which are specifically developed to help with transitioning people from institutions back into their own homes –

Money follows the person is one such Medicaid program for helping people to leave nursing facilities, and to relocate them back to their own homes – this can include assisted living.

Any durable medical equipment which is considered to be necessary for the beneficiaries to return to, and to live in, their homes is bought by the program.

Once again what qualifies as DME is less limited than for Medicare.

What if your revenue is too high to qualify for Medicaid ?

The Spend Down Program

Simply put, Spend-Down programs reduce a person’s income level so that they may become eligible for Medicaid, HCBS’s and waivers.

The simplest method by which this is achieved, is to subtract a person’s medical expenses from their income, and if as a result their income level falls below the Medicare eligibility limit, the person will then qualify.

Unfortunately, not that many states have a Spend-Down program, but if yours does it may be just what you need.

Do check with your Area Agency on Aging, as some states have a similar program but under a different name.

 US NEWS has an article which covers the topic here.

How do you purchase DME on Medicaid state programs or waivers ?

  • a doctor, or therapist, need to write a medical justification letter for you, which states that your equipment is medically necessary
  • the medical justification letter then needs to be given to a Medicaid-approved DME supplier
  • the Medicaid-approved supplier will then fill out what is called a Prior Approval Application
  • the Prior Approval document is delivered to the Medicaid state office for  approval or refusal
  • if your claim doesn’t succeed, you will be notified by Medicaid as to why, and as to how you may appeal their decision
  • if your claim was successful the supplier will have it delivered to you

Looking for HCBS programs, waivers and 1915 waivers and their eligibility criteria in your state

To find what is available in your state click here.

Step 1 –

Find your state on the map.

Step 2

Click on you state 

Step 3 –

Choose –

  • your state Medicaid Agency marked with a (1), or
  • your state Home and Community Based Services, Waivers and 1915 Waivers marked with a (2)

You will then see a page like the example below, with the programs and waivers in your state, and their eligibility criteria.

To find your State Medicaid State Agency

If you want to discuss things, or to email someone, you can contact you state Medicaid Agency here.

Step 1 –

Click the link to Medicade.gov and look for the section that I have outlined in red.

Step 2 –

Select your state and click on the button they have marked “GO” – it will take you to your State Medicaid Agency with all their contact info.

State Funding Assistance

Assistive Technology Programs

The government gives all states across the US have what is called a State Assistive Technology Grant.

With this grant each state sets up their own State Assistive Technology Program, to improve access to assistive devices in the home primarily for the elderly and the disabled.

State Assistive Technology Programs will usually have  –

  • an online equipment and devices exchange where people can post used assistive devices and medical equipment for donation, sale or exchange – any state resident can just register and participate
  • a main website where you can keep abreast of their activities and ask about how to get access to free equipment
  • reuse, recycling and refurbishment programs which are run by the state program, sometimes in partnership with local community groups and non-profits, to provide free or low cost equipment for the disabled and the elderly
  • loan closets are also often a part of their projects, and are either long term or short term, or both

 

Assistive Technology Programs will also have register people who are eligible and need help, and will then contact them when specific equipment which they need becomes available.

Your State Assistive Technology Program website will have the information on the different services.

To see what projects are in your state click here

Follow the steps below to see the projects in your state

 

Step 1/

Pick your state on the map or the drop down menu, and click on “Go to state”

– I chose Florida for this example

Step 2/

Click on the link “Program Title” – for my example I outlined it in red.

Step 3/

The AT Program state website will come up, and you can register, or use their contact info .

State Financial Assistance Programs

As well as the programs we have looked at, some states have non-Medicaid programs which help the elderly and the disabled to maintain their independence homes with financial assistance.

State Financial Assistance Programs will help to purchase assistive devices, safety equipment, durable medical equipment, as well as necessary home modifications.

The participants may get grants or loans, or both.

Your local Area Agencies on Aging should be able to advise on programs for the elderly, and in particular if there is one in your state.

    Summary

    You can get an adjustable hospital bed covered 80% by Original Medicare, but it will only be a basic model that fulfills your medical needs, and you will have to follow the right procedure for it be covered as fully as possible.

    If Medicare agrees that your claim meets their criteria, you will still have to pay at least the co-pay which is 20% of the Medicare approved price of the bed.

    If you wish to have an upgraded model you can arrange to pay the difference yourself.

    Don’t forget, when talking with the DME supplier, to make sure that you ask if they are a Participating Supplier who accepts “assignment”. 

    If Medicare doesn’t cover your claim, you may still be able to get help through a state HCBS program, or waiver, or if you are a veteran you can look at the different pensions which will help with this.

    There are also non-Medicaid state plans which exist to help the elderly maintain their independence in their own home, for which you may qualify if the bed is critical to you maintaining your independence. You can find out about these at your local Area Agency on Aging offices – here is a link to the National Association of Area Agencies on Aging which has a locator for local agencies – click here.

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    Article Name
    Will Medicare pay for an adjustable bed ?
    Description
    Yes, Original Medicare Part B will cover some adjustable beds - basic hospital beds.  You will. though, have to follow a strict process to get them covered.
    Author
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    Lookingaftermomandad.com