Canes are generally covered by Medicare, but only under specific circumstances that classify them as medically necessary devices to assist with mobility. These assistive devices offer support for stability and independent movement, often helping to prevent falls for beneficiaries with temporary or chronic mobility limitations. Obtaining a cane through Medicare requires navigating specific rules designed to ensure the equipment is appropriate for the individual’s condition.
Canes as Durable Medical Equipment Under Medicare Part B
Canes are classified by Medicare as Durable Medical Equipment (DME), which falls under the coverage of Medicare Part B, the program’s Medical Insurance component. DME is defined as equipment that is durable, meaning it can withstand repeated use, and is primarily used for a medical purpose, not simply for convenience or comfort. The equipment must generally not be useful to someone who is not sick or injured and must be appropriate for use in the patient’s home, with a life expectancy of at least three years.
Because canes are considered inexpensive or routinely purchased items, they are typically bought outright rather than rented.
Medicare Part B establishes the foundational rule for payment once all eligibility requirements are met. The program pays 80% of the Medicare-approved amount for the DME. This payment structure means the beneficiary is financially responsible for the remaining 20% of the approved cost, which is known as coinsurance. This 80/20 split is the standard model for covering DME expenses under Part B, assuming the annual deductible has been satisfied.
Essential Steps to Ensure Coverage
For a cane to be covered by Medicare Part B, the beneficiary must first establish medical necessity, which requires documentation from a healthcare provider. A physician or other treating practitioner, such as a nurse practitioner or physician assistant, must prescribe the cane. This prescription serves as a detailed written order that attests to the medical need for the device.
The medical necessity criteria focus on the patient’s functional ability, specifically a mobility limitation that significantly impairs the ability to perform mobility-related activities of daily living (MRADLs) within the home. Documentation must show that the person is unable to walk without assistance or is at a heightened risk of morbidity or mortality from attempting to walk unaided. The treating professional must also confirm that the patient is able to safely use the cane and that the mobility deficit can be sufficiently resolved by its use.
The second mandatory step involves obtaining the cane from a supplier that is enrolled in Medicare. This is a critical administrative step, as Medicare will not cover the cost if the equipment is purchased from a non-approved source. Additionally, the supplier should agree to “accept assignment,” which means they accept the Medicare-approved amount as payment in full.
A supplier who accepts assignment agrees to only bill the beneficiary for the deductible and the 20% coinsurance amount. Following these procedural steps ensures the claim will be processed under the Part B coverage rules.
Calculating Out-of-Pocket Costs
Even when a cane is covered, the beneficiary is responsible for certain out-of-pocket costs, which primarily include the annual Part B deductible and the coinsurance. Before Medicare Part B begins to pay its 80% share of the approved cost, the beneficiary must first meet the yearly deductible. If the cost of the cane is less than the remaining deductible, the beneficiary may pay the full price.
After the deductible is met, the patient is responsible for the 20% coinsurance of the Medicare-approved amount for the cane. The Medicare-approved amount is the maximum amount the program will recognize as payment for the item or service.
Beneficiaries should exercise caution when dealing with suppliers who do not accept assignment. These suppliers are permitted to charge more than the Medicare-approved amount, which is known as balance billing. The beneficiary must pay the remaining 20% coinsurance and any difference between the supplier’s charge and the Medicare-approved amount.
To mitigate these out-of-pocket costs, many beneficiaries rely on supplemental coverage, such as a Medigap policy or a Medicare Advantage plan. Medigap plans are designed to help cover the gaps in Original Medicare, often paying the 20% coinsurance and sometimes the deductible. Medicare Advantage plans must cover the same DME items but may have different cost-sharing structures and networks.