Medicare Coverage for Home Medical Equipment & Qualification Criteria
Medicare Part B (Medical Insurance) covers medically necessary DME if your Medicare-enrolled doctor or other health care provider prescribes it for use in your home. In addition to a prescription from your Dr, Medicare also requires that a provider obtain a copy of your "chart notes" from the visit with your Dr. These notes will need to clearly document that the specific requirements to qualify for specific equipment are met. See specific qualifications for each particular equipment listed below:
Commodes**
- A commode is only covered when you are physically incapable of utilizing regular toilet facilities. For example:
- You are confined to a single room, or
- You are confined to one level of the home environment and there is no toilet on that level, or
- You are confined to the home and there are no toilet facilities in the home.
- Heavy-duty commodes are covered if you weigh over 300 pounds.
- Commodes with detachable arms are covered if your body configuration requires extra width, or if the arms are needed to transfer in and out of the chair.
** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.
Compression Stockings
- Gradient compression stockings worn below the knee are covered only when used for the treatment of open venous stasis ulcers. They are not covered for the prevention of ulcers, prevention of the reoccurrence of ulcers, or treatment of lymphedema or swelling without ulcers.
Hospital Beds**
- A hospital bed is covered if you have visited your doctor or healthcare provider and during an office visit your doctor or healthcare provider documents in your chart that one or more of the following criteria (1-4) are met:
- 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.
- Specialty beds that allow the height of the bed to be adjusted are covered if you require this feature to permit transfers to a chair, wheelchair or standing position.
- A semi-electric bed is covered if your medical condition requires frequent changes in body position and/or you have an immediate need for a change in body position.
- Heavy-duty/extra-wide beds can be covered if you weigh over 350 pounds.
- The total electric bed is not covered because it is considered a convenience feature. If you prefer to have the total electric feature, you will need to sign an Advance Beneficiary Notice (ABN) and will be responsible to pay the difference in the retail charges between the two items.
- Hospital beds are a capped rental item, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.
Mobility Products: Canes, Walkers, Rollators, Wheelchairs, Scooters and Power Wheelchairs**
- Essentially the Medicare policy on mobility products requires that Medicare funds are only used to pay for:
- Mobility needs for daily activities within the home
- The lowest level of equipment required to accomplish these tasks in a timely manner
- The most medically appropriate equipment (that meets your needs, not your wants)
- Medicare requires that your physician or healthcare provider and supplier evaluate your needs and expected use of the mobility product to determine which item 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, will a rollator (4 wheel walker with seat and brakes) allow you to accomplish these activities in the home? *chart notes must document justification for seat*
- 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?
- Your home must be evaluated to ensure it will accommodate the use of wheelchairs and any power mobility devices.
- A face-to-face examination with your physician or healthcare provider to specifically discuss your mobility limitations and need for powered mobility is required prior to the initial setup of a power chair, scooter or manual wheelchair.
- For power mobility items you may also be asked to see a physical therapist or occupational therapist to determine the best fit and equipment selection.
- The majority of all manual and power wheelchairs are considered capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Depending on which product is ordered, your supplier may not be able to deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.
Patient Lifts**
- A lift is covered if transfer between a bed and a chair, wheelchair, or commode requires the assistance of more than one person and, if without the use of a lift, you 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, you will need to sign an Advance Beneficiary Notice (ABN) and would be responsible to pay the difference in the retail charge.
- Patient lifts are considered to be capped rental items, and that means they cannot be purchased outright. You will own the equipment after Medicare makes 13 payments toward the purchase of the equipment.
- Your supplier cannot deliver this product to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.
Seat Lift Mechanisms (Lift Chair)**
- Medicare will only pay for the lift mechanism portion of a lift chair. 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.
- In order for Medicare to pay for a seat lift mechanism, you must be suffering from severe arthritis of the hip or knee, or have a severe neuromuscular disease. In addition you must be completely incapable of standing up from any chair, but once standing can walk either independently or with the aid of a walker or cane. The physician or healthcare provider must believe that the mechanism will improve, slow down or stop the deterioration of your condition.
- Transferring directly into a wheelchair will prevent Medicare from paying for the device.
- Your supplier cannot deliver this product to you without a written order or certificate of medical necessity from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
- New established requirements by the Affordable Care Act require a specific office visit with your physician or healthcare practitioner to assess and document your need for this equipment take place and must then issue a detailed written prescription.
** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.
Support Surfaces**
- Group 1 products are designed to be placed on top of a standard hospital bed or home mattresses. They can utilize gel, foam, water or air, and are covered if you are:
- Completely immobile OR
- Have limited mobility or any stage ulcer on the trunk or pelvis (and one of the following):
- impaired nutritional status
- fecal or urinary incontinence
- altered sensory perception
- compromised circulatory status
- Group 2 products take many forms, but are typically powered pressure reducing mattresses or overlays. They are covered if you have 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 where you were immediately placed on Group 2 or 3 support surface prior to discharge from the hospital and you have been discharged within the last 30 days.
- A physician or healthcare provider must make monthly assessments as to whether continued use of the equipment is required. Sometimes your physician or healthcare provider may order a home healthcare nurse to come visit you to make these assessments.
- Medicare will only pay for the rental of a Group 2 product until your ulcers completely heal. If your ulcers have healed you must return the equipment to your supplier or make arrangements to pay for future monthly rentals privately using an Advance Beneficiary Notice (ABN).
- Group 3 products are air-fluidized beds and are only covered if you meet ALL of the following conditions:
- A stage III or stage IV pressure ulcer, and
- Are bedridden or chair bound as the result of limited mobility, and
- In the absence of an air-fluidized bed would require institutionalization, and
- An alternate course of conservative treatment has been tried for at least one month without improvement of the wound, and
- All other alternative equipment has been considered and ruled out.
- A physician or healthcare provider must assess and evaluate you after completion of a course of conservative therapy within one month prior to ordering the Group 3 support surface.
- A trained adult caregiver must be available to assist you. Medicare does not cover the cost of hiring a caregiver, or for structural modifications to your home to accommodate this equipment.
- Your supplier cannot deliver these products to you without a written order from your doctor or healthcare provider, nor can they get the documentation at a later date because if they do, Medicare can never make payment for those products to you or your supplier. So please be patient with your supplier while they collect the required documentation from your physician or healthcare provider.
** Some or all of the products in this category may be subject to competitive bidding depending on where you live. Ask your supplier for details.
Urological Supplies
- Urinary catheters and external urinary collection devices are covered to drain or collect urine if you have permanent urinary incontinence or permanent urinary retention. Permanent incontinence and retention are defined as a condition that is not expected to be medically or surgically corrected within 3 months.
- A maximum of six catheters may be used per day (up to 200 per month), unless it is determined that a higher number is medically necessary by your physician or healthcare provider, and these unique circumstances are specifically documented in your medical records.
- When at home, you may receive up to a 3-month supply at one time.
Non-covered items (partial listing):
- Adult diapers
- Bathroom safety equipment
- Hearing aides
- Syringes/needles
- Van lifts or ramps
- Exercise equipment
- Humidifiers/Air Purifiers
- Raised toilet seats
- Massage devices
- Stair lifts
- Emergency communicators
- Low vision aides
- Grab bars
- Elastic garments
