A shower chair, or bath bench, is safety equipment providing secure seating for individuals who have difficulty standing for extended periods in a wet environment. This device is particularly beneficial for those with mobility issues, balance concerns, or generalized weakness, helping to mitigate the significant risk of falls in the bathroom. By providing a stable base during bathing, a shower chair promotes personal independence and helps maintain hygiene with reduced physical strain. Obtaining one through a health insurance plan, however, depends entirely on documenting a specific medical necessity and navigating the insurer’s procedural requirements.
Establishing the Need for Durable Medical Equipment
The first step in seeking coverage is understanding the classification of the item as Durable Medical Equipment (DME). DME is defined by insurers, including Medicare, as equipment that is durable, can withstand repeated use, is used for a medical reason, is not generally useful to someone who is not sick or injured, and is appropriate for use in the home. Items like wheelchairs and hospital beds typically meet these criteria and are covered.
A shower chair often falls into a gray area, frequently classified as a “convenience item” rather than a true DME item necessary for treating a condition. Coverage hinges on establishing clear “medical necessity,” which requires a physician’s documentation. The physician must certify that the patient cannot safely perform the activity of daily living—bathing—without the device and that the chair is necessary to prevent injury, such as a fall, due to a diagnosed medical condition or disability.
This documentation must be specific, including detailed medical records, diagnosis codes related to the mobility issue, and sometimes a physical therapy evaluation. A simple prescription is often insufficient; the insurer requires a comprehensive Certificate of Medical Necessity (CMN). The CMN must link the chair directly to the patient’s medical treatment plan and safety. Without this clear, documented justification, insurance carriers will deny the claim.
Understanding Coverage by Insurance Type
Coverage varies significantly across different insurance programs based on how each defines and covers DME.
Original Medicare
Original Medicare (Part B) generally does not cover shower chairs. Medicare considers them personal comfort or safety items, not medically necessary equipment for treating an illness or injury. Out-of-pocket payment is the typical outcome for beneficiaries. However, specialized equipment, like a rolling commode chair that can be used in the shower, may be covered if prescribed as medically necessary for toileting and if it meets all DME requirements.
Medicare Advantage and Medicaid
Medicare Advantage plans, offered by private companies, often include supplemental benefits that exceed Original Medicare. These plans may offer over-the-counter allowances or specific coverage for bathroom safety equipment, which could include a shower chair. Medicaid, the joint federal and state program for low-income individuals, tends to offer broader coverage for bath aids, but this is highly state-dependent. Many state Medicaid programs will cover a shower chair if a doctor deems it medically necessary for safe personal hygiene activities at home. For dual-eligible beneficiaries (Medicare and Medicaid), Medicaid may cover the item after Medicare formally denies the claim.
Private Insurance
Private insurance coverage depends entirely on the specific policy’s language and its definition of DME and covered benefits. Some private plans exclude shower chairs, following strict guidelines. Others may cover them with a physician’s prescription and proof of medical necessity for a chronic condition or disability. To confirm coverage, contact the insurer directly and ask about their policy on bathroom safety equipment or assistive devices.
The Acquisition and Claim Submission Process
Once medical necessity is determined and coverage is possible, the acquisition process begins with necessary paperwork. The physician must provide a detailed prescription, often the Certificate of Medical Necessity (CMN), which explicitly states the patient’s diagnosis and how the chair addresses a medical need. This document, along with supporting clinical notes, forms the foundation of the insurance claim.
The patient must select a Durable Medical Equipment (DME) supplier who is in-network with the insurance plan and accepts assignment. Using an in-network supplier is crucial because they are bound by a contract to accept the insurer’s approved payment rate, limiting the patient’s financial responsibility. The DME supplier manages the administrative burden, including the critical step of Prior Authorization (PA).
PA is a pre-approval process where the supplier submits the CMN and medical records to the insurance company before the chair is delivered. This confirms the item meets the payer’s coverage rules and is medically necessary, helping to avoid later claim denials and unexpected bills for the patient. After receiving the affirmative PA decision and delivering the equipment, the supplier submits the final claim for payment.
Managing Costs and Coverage Denials
Even with an approved claim, the patient is often responsible for out-of-pocket costs, such as co-payments, co-insurance, and meeting the annual deductible. For a covered DME item under Medicare Part B, the patient pays 20% of the Medicare-approved amount after the deductible has been met. It is important to confirm the exact cost-sharing amounts with the DME supplier before accepting the equipment.
If the claim is denied, the insurance company must send an Explanation of Benefits (EOB) detailing the reason for the rejection. Common reasons for denial include classification as a “convenience item,” missing documentation, or insufficient proof of medical necessity. The patient has the right to appeal this decision, which usually begins with an internal appeal asking the insurer to reconsider the claim with additional medical evidence, such as a more detailed letter from the prescribing physician.
If the appeal is unsuccessful, practical alternatives exist for obtaining a shower chair at a low cost.
Low-Cost Alternatives
- Local organizations, such as non-profits, senior centers, or centers for independent living, operate medical equipment loan closets that provide durable equipment free of charge or for a small fee.
- Veterans Affairs (VA) benefits or state-specific programs may provide assistance.
- The purchase cost may qualify as a tax-deductible medical expense if prescribed for a documented condition.