A standard mattress is not covered by Medicare because it is not considered medical equipment. Medicare provides coverage for items that are medically necessary to treat or prevent a specific illness or condition. Specialized bedding, such as certain mattresses and support surfaces, may qualify for coverage under strict rules. These items must be classified as Durable Medical Equipment (DME), and a healthcare provider must document the specific medical need to qualify for financial assistance.
Defining Medical Necessity for Specialized Bedding
A fundamental distinction exists between an ordinary consumer mattress and a specialized medical support surface that Medicare might cover. The specialized equipment must serve a therapeutic purpose, meaning it is necessary to prevent or treat a severe medical condition. This necessity is commonly tied to individuals who are largely immobile and face a high risk of developing pressure ulcers, often referred to as bedsores.
These ulcers are localized injuries to the skin and underlying tissue, usually occurring over a bony prominence due to prolonged pressure. Specialized mattresses work to redistribute body weight, which lowers the interface pressure between the skin and the support surface, maintaining tissue perfusion. A physician must document that the patient requires this specific type of pressure reduction, often due to existing stage II, III, or IV ulcers, or for prophylactic measures in high-risk patients.
Medicare Rules for Durable Medical Equipment Coverage
Specialized support surfaces fall under the category of Durable Medical Equipment (DME), which is typically covered under Medicare Part B. To qualify, the equipment must be robust enough to withstand repeated use and have an expected lifespan of at least three years. The equipment must also be primarily for a medical purpose and generally not useful to someone who is not ill or injured.
Coverage requires a formal prescription from a physician or other authorized healthcare provider, detailing the medical necessity. Documentation must confirm the equipment will be used in the patient’s home, including long-term care facilities that do not primarily provide skilled care. The item must be obtained from a Medicare-approved supplier to ensure compliance with regulatory standards.
The supplier must accept assignment, agreeing to Medicare’s approved payment amount. This ensures beneficiaries receive necessary medical devices while managing costs. The process is governed by guidelines established by the Centers for Medicare and Medicaid Services (CMS).
Examples of Covered Pressure-Reducing Equipment
Pressure-reducing support surfaces are categorized into distinct groups based on complexity and the severity of the condition they treat. Group 1 surfaces include non-powered pressure pads and simple mattress overlays, often made of foam, gel, or air, placed on top of a standard mattress. These devices are used for patients at risk of skin breakdown who can still make some positional changes independently.
Group 2 support surfaces are more advanced, often featuring powered components like alternating pressure mattresses or low air loss systems. An alternating pressure mattress uses a pump to cyclically inflate and deflate air cells, constantly shifting the pressure points on the patient’s body to prevent prolonged compression. Low air loss mattresses circulate air through porous fabric to manage skin moisture and temperature, which is a significant factor in preventing skin breakdown.
The most advanced category is Group 3, limited to air-fluidized beds. These beds suspend the patient on a cushion of air created by forcing air through fine ceramic microspheres, resulting in a sensation similar to flotation. Coverage for these devices is reserved for patients with severe, non-healing pressure ulcers (Stage III or Stage IV), or those with myocutaneous flaps or skin grafts. These surfaces are often used with a hospital bed that is also medically necessary.
Understanding Patient Financial Responsibility
Once a specialized support surface is approved as medically necessary DME, the patient still has financial obligations under Medicare Part B. After the annual Part B deductible is met, Medicare covers 80% of the approved amount for the equipment. The beneficiary is responsible for the remaining 20% coinsurance.
This 20% coinsurance applies whether the equipment is rented or purchased, depending on Medicare’s coverage rules. For example, many support surfaces are initially rented, with ownership transferring to the patient after a certain number of rental payments. Patients with supplemental insurance, such as a Medigap policy, may have their 20% coinsurance obligation covered entirely or partially by that secondary plan.