Medicare Coverage and other Insurance for Specific Types of Home Medical Equipment
A commode is only covered when the patient is physically incapable of utilizing regular toilet facilities. For example: The patient is confined to a single room, or the patient is confined to one level of the home environment and there is no toilet on that level, or the patient is confined to the home and there are no toilet facilities in the home.
Heavy-duty commodes are covered for patients weighing over 300 pounds.
A hospital bed is covered if one or more of the following criteria (1-4) are met: The patient has 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 the patient requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or the patient requires 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 The patient requires traction equipment which can only be attached to a hospital bed.
Specialty beds that allow the height of the bed to vary are covered for patients that require this feature to permit transfers to a chair, wheelchair, or standing position.
A semi-electric bed is covered for a patient who requires frequent changes in body position and/or has an immediate need for a change in body position.
Heavy-duty/extra-wide beds can be covered for patients who weigh over 355 pounds.
The total electric bed is not covered because it is considered a convenience feature. If the patient prefers to have the total electric feature, the provider usually can apply the cost of the semi-electric bed toward the monthly rental price of the total electric model by using an Advance Beneficiary Notice (ABN). The patient would be responsible to pay the difference in the retail charges between the two items every month.
Mobility Products: Canes, Walkers, Wheelchairs, and Scooters
Essentially the new Mobility Assistive Equipment regulations will ensure that Medicare funds are used to pay for:
Mobility needs for daily activities within the home
Least costly alternative/lowest level of equipment to accomplish these tasks.
Most medically appropriate equipment (to meet the needs, not the wants)
Medicare requires that your physician and provider evaluate your needs and expected use of the mobility product you will qualify for.
They must determine which is the least level of equipment needed to help you be mobile within your home to accomplish daily activities by asking the following questions:
Will a cane or crutches allow you to perform these activities in the home?
If not, will a walker allow you to accomplish these activities in the home?
If not, is there any type of manual wheelchair that will allow you to accomplish these activities in the home?
If not, will a scooter allow you to accomplish these activities in the home?
If not, will a power chair allow you to accomplish these activities in the home?
Keep in mind if you have another higher level product in mind that will allow you to do more beyond the confines of the home setting, you can discuss with your provider the option to upgrade to a higher level or more comfortable product by paying an additional out of pocket fee using the Advance Beneficiary Notice (ABN) to select the product you like best.
A face-to-face examination with your physician is required prior to the initial setup of a power chair or scooter.
Your home must be evaluated to ensure it will accommodate the use of any mobility product.
A lift is covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the patient would be bed confined.
An electric lift mechanism is not covered because it is considered a convenience feature. If you prefer to have the electric mechanism, your provider can usually apply the cost of the manual lift toward the purchase price of the electric model by using an Advance Beneficiary Notice (ABN). You would be responsible to pay the difference in the retail charges between the two items.
Seat Lift Mechanisms
In order for Medicare to pay for a seat lift mechanism, patients must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition they must be completely incapable of standing up from any chair, but once standing they can walk either independently or with the aid of a walker or cane. The physician must believe that the mechanism will improve, slow down, or stop the deterioration of the patient’s condition.
Transferring directly into a wheelchair will prevent Medicare from paying for the device.
Medicare will only pay for the lift mechanism portion. The chair portion of the package is not covered, and you will be responsible for paying the full amount for the furniture component of the chair.
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Group 1 products are designed to be placed on top of a standard hospital or home mattress. They can utilize gel, foam, water, or air, and are covered for patients who are:
Completely immobile OR have limited mobility with any stage ulcer on the trunk or pelvis (and one of the following): Impaired nutritional status, Fecal or urinary incontinence, Altered sensory perception or Compromised circulatory status
Group 2 products take many forms, but are typically powered pressure reducing mattresses or overlays. They are covered for patients with one of three conditions:
Multiple stage II ulcers on the pelvis or trunk while on a comprehensive treatment program for at least a month using a Group 1 product, and at the close of that month, the ulcers worsened or remained the same. (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR large or multiple Stage III or IV ulcers on the trunk or pelvis (Monthly follow-up is required by a clinician to ensure that the treatment program is modified and followed. This product is only covered while ulcers are still present.) OR a recent myocutaneous flap or skin graft for an ulcer on the trunk or pelvis within the last 60 days who were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital and the patient has been discharged within last 30 days.