The cost of specialized mattresses and adjustable beds can be a serious concern for seniors who need them for medical reasons. Medicare may cover these items, but only specific types of equipment classified as Durable Medical Equipment (DME) are eligible, and strict medical necessity criteria must be met to secure coverage. Standard mattresses purchased for general comfort or common conditions like simple back pain are not covered, as they do not meet the definition of medical equipment. The primary focus of Medicare coverage is on items that provide therapeutic benefits directly related to a serious illness or injury.
Defining Covered Durable Medical Equipment
Medicare Part B covers DME, which includes certain types of mattresses and beds for use in the home. To qualify as DME, the equipment must be durable, used for a medical purpose, generally not useful to someone without an illness or injury, used in the home, and expected to last for at least three years. Standard mattresses, even high-end ones, typically fail to meet the “medical purpose” criteria.
The types of sleeping surfaces covered fall mainly into two categories: hospital beds and specialized pressure-reducing support surfaces. A hospital bed is often covered if the beneficiary requires positioning that cannot be achieved with a regular bed, such as head or foot elevation to alleviate pain, difficulty breathing, or swelling in the legs. These beds include the frame and a standard mattress designed for a hospital bed.
Specialized mattresses, often referred to as pressure-reducing support surfaces, are covered when a patient is at risk of developing or already has pressure ulcers, commonly known as bedsores. These surfaces can be overlays placed on an existing mattress or full mattress replacements utilizing advanced features like low-air-loss or alternating pressure. The purpose of these surfaces is to redistribute body weight and reduce the interface pressure that can lead to tissue damage.
Establishing Medical Necessity for Coverage
Coverage for these specialized items is strictly dependent on a physician’s determination of medical necessity, which must be documented in the patient’s medical record. For a hospital bed, the need must be tied to a specific medical condition, such as severe immobility, a need for frequent changes in body position, or the requirement for traction equipment that only a hospital bed can accommodate. The physician must issue an order explaining how the bed will address the patient’s condition.
The criteria for pressure-reducing support surfaces are highly detailed and focus on preventing or treating pressure ulcers. For example, a Group 2 support surface, such as a powered air or non-powered advanced mattress, may be covered if the patient has multiple Stage II pressure ulcers that have not improved after a month of comprehensive treatment. Coverage may also be granted for patients with large or multiple Stage III or IV pressure ulcers on the trunk or pelvis.
A Group 3 support surface, like an air-fluidized bed, represents the highest level of coverage and is reserved for the most severe cases. To qualify for this type of bed, the patient must typically have a Stage III or IV pressure ulcer covering a significant area of the body and must have failed to heal after a month of conservative treatment, including the use of a Group 2 surface.
Steps for Securing Medicare Coverage and Understanding Costs
Obtaining the Prescription and Documentation
The process for securing coverage begins when the treating physician prescribes the specific durable medical equipment for home use. The physician’s order must clearly state the medical reason for the equipment and the duration it is needed. While the “Certificate of Medical Necessity” (CMN) form has been discontinued for many DME items, the information previously contained in it must still be clearly documented in the patient’s medical records to justify the claim.
Working with Suppliers
The next step involves obtaining the equipment from a DME supplier who is enrolled with and accepts assignment from Medicare. Accepting assignment means the supplier agrees to accept the Medicare-approved amount as full payment. If a supplier does not accept assignment, the beneficiary may be responsible for paying the entire bill upfront and could incur higher costs.
Understanding Costs and Rental Programs
Coverage falls under Medicare Part B, and the patient is responsible for out-of-pocket costs after the annual Part B deductible is met. Medicare typically pays 80% of the Medicare-approved amount for the equipment, leaving the beneficiary responsible for the remaining 20% coinsurance. For hospital beds and some specialized mattresses, Medicare often employs a capped rental program, where the equipment is rented for a set period, typically 13 months, after which ownership transfers to the patient.