by Russell Noga | Updated February 1st, 2024
Does Medicare cover mattresses? The short answer is yes, under specific conditions. If a doctor prescribes a mattress as medically necessary and it qualifies as durable medical equipment (DME), Medicare Part B coverage may apply. This article unpacks the criteria for coverage, the necessary steps to obtain approval, and the financial implications for those qualifying for a medicare coverage for mattress.
Key Takeaways
- A mattress is considered medically necessary by Medicare if it helps to position the body in specific ways that a regular bed cannot, which is assessable by a patient’s physician.
- Medicare Part B covers 80% of the approved amount for a mattress deemed medically essential and classified as Durable Medical Equipment, leaving beneficiaries responsible for deductibles and co-insurance.
- Medicare typically covers hospital beds and pressure-reducing mattresses but does not extend coverage to all mattress types unless they meet specific medical necessity criteria.
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Navigating Medicare Mattress Eligibility
You may know Medicare as a health insurance program for people aged 65 or older. You might be surprised to learn that Medicare could potentially bear 80% of the cost for a new mattress, pending a physician’s certification of its medical necessity. But what exactly does “medically essential” mean? Well, let’s decode that.
According to Medicare, a mattress is medically necessary if it’s needed to position the body in ways that a regular bed can’t achieve. Furthermore, the patient’s doctor must ascertain that the mattress is medically essential to their health and well-being. So, if you thought Medicare coverage was just about doctor visits and prescription drugs, you’re in for a pleasant surprise.
Decoding Part B Coverage for Your Sleep Surface
Medicare Part B, which classifies Medicare-approved mattresses under durable medical equipment (DME), can pave the way to a good night’s sleep. But there are a few hoops to jump through before the coverage kicks in.
If a doctor agrees to Medicare assignment, they must follow these steps:
- Determine if a Medicare-approved mattress is medically necessary to treat or manage a chronic condition before prescribing it.
- Based on your specific needs and Medicare regulations, you may either rent or purchase the mattress, or choose between the two options.
- The mattress must be procured from a roster of Medicare-approved suppliers.
The Role of Durable Medical Equipment in Coverage
Durable Medical Equipment (DME), in essence, is equipment that can endure frequent use, is recommended by a healthcare provider, and is needed for a patient with a medical condition. And if a mattress fits these criteria, it might just be covered by Medicare.
Evaluating if a mattress fulfills the DME criteria is vital, as it largely influences whether Medicare will shoulder the mattress expenses, also known as Medicare mattress coverage. If approved, Medicare Part B will cover 80% of the approved amount for the mattress, leaving you responsible for any relevant deductibles, co-payments, or co-insurance.
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Types of Mattresses That Medicare Approves
Medicare’s coverage does not extend to all mattress types. Therefore, it’s crucial to confirm coverage before proceeding with a purchase. But it does cover specific ones, like hospital beds and pressure-reducing mattresses, provided certain criteria are met. These criteria could include having a medical need documented, such as being bedridden due to immobility or an injury, or having a prescription from a physician to alleviate back pain.
And if you’re wondering about orthopedic mattresses, the news is good. They might be covered if they’re deemed medically necessary for alleviating back pain and are recommended by a physician. So, while you might not get coverage for that lavish, plush-top mattress, you can get significant financial help for a mattress that’s medically necessary.
When Pressure Reducing Mattresses Become Necessary
You might wonder when the need for a pressure-reducing mattress arises. Let’s examine the criteria set by Medicare. They include:
- Eligibility for a defined Medicare benefit category
- Reasonableness and necessity for the diagnosis or treatment of an illness or injury
- Improving the functioning of a malformed body member
Health conditions that might require a pressure-reducing mattress include prolonged immobility, poor nutrition, and comorbid medical conditions. And if you’re suffering from pressure ulcers, you could be eligible for an air-fluidized bed through Medicare. Just remember that Medicare mandates obtaining prior authorization for pressure-reducing mattresses.
Financial Aspects of Medicare Covered Mattresses
Time to delve into the financial aspect. If your application is approved, Medicare Part B will bear 80% of the Medicare approved amount for a medically necessary mattress. You’re responsible for any relevant deductibles, co-payments, or co-insurance. For example, if you’re eyeing a pressure relief mattress, your out-of-pocket expense could be around $458.
Medicare-approved beds and mattresses can range in price from $500 to $30,000 and higher. The cost varies depending on features and specifications. But remember, the costs and copays for Medicare-covered mattresses vary based on the specifics of your Medicare Advantage plan. So, be sure to check your plan details.
Adjustable Beds and Medicare: What You Need to Know
For those contemplating an adjustable bed, good news might be on the horizon. Medicare cover adjustable beds if the bed is determined to be medically necessary for conditions that necessitate frequent repositioning. These conditions could include:
- Body pains
- Cardiac diseases
- Severe arthritis
- COPD
- Spinal cord injuries like quadriplegia or paraplegia.
And the good news doesn’t stop there. If you have Medicare coverage for adjustable beds, you could be eligible for financial assistance to cover any deductibles or copays that you’re responsible for.
Getting a New Mattress Through Medicare Advantage Plans
Procuring a new mattress through Medicare Advantage Plans may be somewhat challenging. Not all Medicare Advantage Plans cover the cost of a new mattress. But when medicare covers mattresses that are deemed medically necessary and are of approved types, these plans generally cover 80% of the cost.
To obtain a new mattress, follow these steps:
- Discuss with your physician to get a prescription for a medically necessary mattress.
- Purchase the mattress from a Medicare-approved supplier.
- Submit a claim to your Medicare Advantage Plan for reimbursement.
Mattresses like the Solace Resolution Glissando Heavy Duty Mattress and Joerns PrevaMatt Defend Pressure Relief could be mattresses covered if prescribed for medical necessity.
The Intersection of Medicaid Services and Mattress Coverage
Medicaid services, too, can significantly influence mattress coverage. Providers need to maintain documentation in line with the coverage criteria, documentation requirements, and Certificate of Medical Necessity. Medicaid coverage for mattresses varies by state, but generally, they’ll pay for hospital beds for at-home use if deemed medically necessary and prescribed by a healthcare provider.
Getting Medicaid coverage for a mattress can be time-consuming and usually involves seeking guidance from Medicaid and potentially other financial aid programs. And yes, Medicaid can cover adjustable beds if they’re deemed necessary for patients with medical conditions that require increased comfort or to mitigate the risk of injury.
Special Considerations for Hospital Bed Coverage
Several special considerations ought to be kept in mind regarding hospital bed coverage. Medicare Part B covers in-home hospital beds as Durable Medical Equipment (DME). But to qualify, you need a prescription from a physician and additional documentation showing the medical necessity.
The approval process for hospital bed coverage is a bit different from other types of beds. It involves a physician’s prescription, the fulfillment of specific criteria, and a detailed evaluation of costs. And while Medicare covers a range of hospital beds, it may not include fully electric beds in this coverage.
Alternative Solutions for Those Not Meeting Criteria
Don’t be disheartened if you don’t meet the eligibility criteria for Medicare or Medicaid coverage. There are still ways to get a specialized mattress. You can seek out the most competitive prices during sales events to procure a cost-effective mattress. If Medicaid doesn’t cover the cost or you don’t meet the eligibility criteria, you can explore alternative funding options, such as private organizations or charities.
Entities like DonationTown, an online directory, and Furniture Bank Network, a network of charities, can provide free beds and mattresses to those in need. And establishments such as Sleep Foundation, NCOA, and The New York Times offer suggestions for mattresses that provide comfort and affordability.
Summary
Navigating Medicare coverage for mattresses can seem like a daunting task. But with the right information, it becomes a manageable journey. Whether it’s understanding eligibility criteria, decoding Medicare Part B coverage, identifying approved mattress types, or exploring alternative solutions, the path to a restful night’s sleep is within reach. So, are you ready to get started?
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Frequently Asked Questions
What kind of mattresses does Medicare pay for?
Medicare typically only covers pressure-reducing mattresses for specific conditions like sciatica and arthritis. This coverage is limited to this type of mattress.
Can a doctor write a prescription for a new mattress?
Yes, a doctor can prescribe a new mattress to treat and manage spinal and back pain issues, but Medicare requires the necessary documents to verify its necessity. Therefore, it is possible under certain circumstances.
Will Medicare pay for a Sleep Number bed?
Yes, Medicare will pay for 80% of the cost of a Sleep Number bed as part of a beneficiary’s Part B benefits, after the Part B deductible has been met.
Can adjustable beds be covered by Medicare?
Yes, Medicare can cover the cost of an adjustable bed if it’s medically necessary for conditions requiring frequent repositioning.
What assistance is available if I don’t meet the criteria for Medicare or Medicaid coverage?
If you don’t meet the criteria for Medicare or Medicaid coverage, you can explore alternative funding options like private organizations or charities, and even reach out to entities like DonationTown or Furniture Bank Network for assistance with a free bed.
Speak to the Professionals about Medigap Plans and Original Medicare
If you find understanding the benefits involved with Original Medicare and Medigap Plans challenging, you’re not alone. Whether it’s a Medigap plan, or you want to know more about Medicare coverage for mattress, we can help. Call our team at 1-888-891-0229 for a free consultation or complete the contact form on this site, and an expert will call you back at a convenient time.
We have decades of experience advising our clients on the complexities of Medicare and Medigap plans, the benefits, cost and deductibles. We’ll ensure you get the best rate in your state and advice you can trust.
Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.