Medicare covers some mattresses, but only under specific circumstances. Coverage is limited to medical-grade mattresses, often called specialized support surfaces, not standard consumer models. Medicare provides this assistance when a doctor determines the specialized mattress is medically necessary for a patient’s health condition and use in their home. This process requires meeting certain criteria and documentation to confirm the equipment is needed to treat or prevent a severe illness or injury.
Mattresses as Durable Medical Equipment
Medicare classifies specialized mattresses and mattress overlays as Durable Medical Equipment (DME), covered under Medicare Part B. To qualify as DME, the item must be durable, expected to last at least three years, and withstand repeated use. The equipment must be primarily used for a medical reason and prescribed for use in the patient’s home.
Specialized mattresses fall under the category of “Pressure-Reducing Support Surfaces.” These surfaces redistribute a patient’s weight to reduce the risk of tissue breakdown and pressure ulcers (bedsores). This category includes static non-powered surfaces, such as high-density foam mattresses, and powered surfaces like alternating pressure mattresses or low air loss systems. Mattresses designed for use with a hospital bed are also included as covered DME.
Qualifying for Coverage Through Medical Necessity
Establishing the medical necessity of the support surface is the most significant hurdle for coverage, requiring a detailed prescription from a physician. The physician’s order must certify the equipment is necessary for treating a medical condition and for use in the patient’s home. Specific documentation must be provided to Medicare to prove the patient meets the coverage criteria. The supplier providing the mattress must also be enrolled in and approved by Medicare.
Medicare distinguishes between different levels of support surfaces, categorized as Group 1 and Group 2, each with strict requirements. A Group 1 surface, typically a non-powered mattress overlay or mattress, may be covered for patients who are completely immobile or have limited mobility. This requires co-existing conditions like impaired nutrition, incontinence, or compromised circulation. Coverage may also apply if the patient has any stage pressure ulcer on the trunk or pelvis.
A Group 2 support surface, which includes powered alternating pressure mattresses or low air loss systems, requires more severe medical evidence. This higher level of support is typically reserved for patients with multiple Stage II pressure ulcers that have not improved after one month of comprehensive treatment, including the use of a Group 1 surface. Coverage is also provided for patients with large or multiple Stage III or IV pressure ulcers. For all levels, the physician must certify the equipment is required to treat an existing severe condition or to prevent imminent, severe complications.
Patient Costs and Payment Rules
Once a specialized mattress is approved as medically necessary DME, the cost is covered under Medicare Part B. The patient must first satisfy the annual Part B deductible before coverage begins. After the deductible is met, Original Medicare typically pays 80% of the Medicare-approved amount for the equipment. The patient is responsible for the remaining 20% coinsurance.
The payment process depends on whether the equipment is rented or purchased. Specialized support surfaces are considered “capped rental items.” Medicare often pays for the rental for a continuous period of use, usually not exceeding 13 months. After a certain number of rental payments, ownership of the equipment may transfer to the patient.
Suppliers who “accept assignment” agree to accept the Medicare-approved amount as full payment and only bill the patient for the deductible and 20% coinsurance. If a supplier does not accept assignment, they may charge the patient more than the Medicare-approved amount. This increases the patient’s out-of-pocket costs. Using a Medicare-approved supplier who accepts assignment helps ensure the lowest possible patient expense.