Does Medicare Cover Bathroom Equipment?

Medicare is a federal health insurance program. Many people wonder about its coverage for home health items, especially those used in a bathroom. While Medicare does not cover all bathroom items, it does provide coverage for some under specific conditions, ensuring support for medically necessary equipment.

Covered Equipment Under Medicare

Medicare coverage primarily extends to items classified as Durable Medical Equipment (DME). For an item to be considered DME, it must be durable, withstand repeated use, serve a medical purpose, not be useful to someone not sick or injured, be for home use, and last at least three years. Medicare Part B covers DME when a doctor or other healthcare provider prescribes it for use in the home.

Regarding bathroom equipment, Medicare Part B may cover items such as commode chairs, especially if a beneficiary is confined to a room without bathroom facilities. Certain types of hospital beds are also covered if medically necessary for home use, which could facilitate transfers in or out of a bathroom area. However, many common bathroom safety items are not covered. These include grab bars, raised toilet seats, and shower chairs or benches, as Medicare considers these convenience items rather than medically necessary durable equipment. Home modifications, such as widening doorways or installing ramps, are also not covered by Original Medicare.

Meeting Medicare’s Coverage Criteria

For Medicare to cover Durable Medical Equipment, several specific criteria must be met. A physician or other authorized healthcare provider must deem the equipment medically necessary for use in the beneficiary’s home. Medical necessity means the item is required to diagnose or treat an illness, injury, condition, or its symptoms, and meets accepted medical standards. Without this determination, coverage is unlikely.

A written order or prescription from the physician is mandatory for most DME items. For some complex equipment, like power mobility devices, a face-to-face encounter between the beneficiary and the prescribing practitioner is also required to document medical necessity. The equipment must be obtained from a supplier enrolled in Medicare to ensure it adheres to program standards and billing practices. DME coverage falls under Medicare Part B, meaning beneficiaries are responsible for 20% of the Medicare-approved amount after meeting their annual Part B deductible.

The Process for Getting Equipment

Obtaining Medicare-covered bathroom equipment begins with a consultation with your doctor. During this visit, discuss your specific needs and obtain a detailed prescription or order for the medically necessary equipment. This order serves as primary documentation of your need, and your medical records must support the medical necessity.

Next, locate a Medicare-approved supplier. These suppliers are enrolled in the Medicare program and agree to accept assignment, meaning they accept the Medicare-approved amount as full payment and can only charge you for the coinsurance and deductible. You can find Medicare-approved suppliers by using the official Medicare website’s supplier directory or by contacting Medicare directly. Confirm with the supplier that they participate in Medicare before obtaining equipment.

Before receiving the equipment, understand your financial responsibility, which includes the Part B deductible and 20% coinsurance of the Medicare-approved amount. If the supplier believes Medicare may not cover the item, they should provide you with an Advance Beneficiary Notice of Noncoverage (ABN). Signing this form indicates your understanding that you may be responsible for the cost if Medicare denies the claim, but it also preserves your right to appeal. If a claim is denied, beneficiaries have the right to appeal the decision through a multi-level process, starting with a redetermination request.