Are mattresses covered by Medicare?

1. Introduction

From the Medicare website, durable medical equipment is defined as “medical equipment that your doctor prescribes for use in the home.” This includes hospital beds or patient lifts if a person has a medical condition requiring positioning of the body in ways not feasible with an ordinary bed. Medicare will cover a medically necessary mattress for a hospital bed, but will not cover an ordinary mattress for the bed. Any physician who receives an order is able to write the request for the mattress. He/she will need to do so with a detailed description of the order as well as a description of the patient’s condition and why it is medically necessary. It is necessary to have these documents submitted with the claim. The patient should appeal if the request is denied as many claims are later approved. The more severe the condition, and the more the ordered mattress has therapeutic qualities, the more likely Medicare will approve the request. This will also affect the amount of reimbursement if Medicare does decide to cover the cost. Anywhere from 80-100% of the cost may be covered if it is fully approved by the documentation. Any money paid beyond the 20% that a patient would be responsible for can be refunded by the supplier. [1][2][3][4][5]

Medicare is a health insurance program in the United States. It is important to understand what types of durable medical equipment are covered, and this article will address whether or not mattresses are covered by Medicare. Medicare is made up of two parts: Part A and Part B. Part A is hospital insurance and covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and home health care. Part B is medical insurance and helps cover doctors’ services, outpatient care, durable medical equipment, and home health care. Either Medicare program will help to cover the cost of a mattress, but there are certain qualifications that must be met.

2. Eligibility for Medicare Coverage

c) The patient is dependent on a palliative care package and has a life-limiting illness and is at high risk of developing a pressure injury. The patient has major functional limitations and/or cognitive impairment and is confined to bed or a chair.

In this scenario, a hospital bed is not required for coverage. For a patient with a wound, a pressure-reducing overlay may be covered under general criteria and does not require the presence of, nor be used on, a hospital bed. Overlays are covered in the patient-specific criteria for most evidenced by the term ‘aids for daily living’. An example of specific criteria from the NSW guidelines is:

b) The patient has a skin graft or a planned flap surgery.

a) Complex and non-complex wounds are covered under the same criteria and are defined as: Complex – a wound that has failed to respond to more than 30 days of treatment or that has not reduced in size by at least 15% over a one-month period. Non-complex (Medicare Part A only) – a wound that has not failed to respond to more than 30 days of treatment and has reduced in size by at least 15% over a one-month period.

When a patient is under the care of a healthcare professional, a mattress or overlay would be covered by Medicare if the patient has a skin condition which is exacerbated by the use of a standard hospital mattress (e.g. becomes worse or has delayed improvement) and meets certain criteria. These conditions are:

2.1. Point 1: Medicare Part A Coverage

During this period, Medicare Part A may pay for inpatient hospital stays, care in a skilled nursing facility, hospice care, and other services. A hospital bed is covered if a doctor declares that it is medically necessary for treatment. Please note that in order for Medicare to cover a hospital bed and/or a mattress, it may need to be supplied by a Medicare-enrolled home health agency, doctor, or hospital. Also, keep in mind that reimbursement for these things is only possible for as long as the home-bound patient continues to require medical treatment and/or recover from an illness or injury. Upon such time as the patient’s medical condition improves to the point where in-home treatment is no longer necessary, Medicare coverage for the bed/mattress will cease. This lack of coverage may then require patient responsibility for rental fees. In cases where a patient has permanently lost use of limbs or is bedridden, he or she may be eligible to have a hospital bed purchased. This must be further clarified with a physician. It should also be noted that as patients continue to utilize Medicare services, there are deductibles and co-payments that will also factor into costs for items such as a hospital bed or mattress. [1][2][6][7]

2.2. Point 2: Medicare Part B Coverage

The first criterion states that coverage is approved if the item is reasonable and necessary for the treatment of illness or injury. The second states that the bed needs to be used in the home. The third states that the patient has no other bed that he/she can use in the home. The fourth states that the patient has a medical condition which requires positioning of the body in ways that can only be achieved with the use of the specific bed being claimed. If the bed can be used for an additional purpose other than the treatment of the patient’s specific illness or injury, the extra expenses will not be covered by Medicare. This includes, but is not limited to, hospital beds. Another important point is that if the patient is living in a facility which already has the items needed for DME, then Medicare will not pay for the rental or purchase of those items.

The most accurate information regarding the question of whether mattresses are covered by Medicare is available from Medicare itself. According to Medicare’s National Coverage Determination in the section of Durable Medical Equipment Reference List (280.1), a bed is covered if all four criteria are met. Each of these criteria is paraphrased, of course.

3. Exclusions from Medicare Coverage

Items and services subject to reasonable and necessary denials may continue to be provided to the patient at their option. Payment liability is assumed in cases where a supplier knows or has reason to know that the item or service will not be considered for coverage or payment, as well as in cases where a beneficiary receives items and services that are identical to those provided for another beneficiary for an indication not covered by Medicare.

3.1.1. Reasonable and Necessary Denial These items and services are excluded from coverage when it is determined that the requirements for coverage are not met. These requirements are: – Establishing that the item or service is reasonable and necessary – Establishing that the item or service is not excluded from coverage – Establishing that the item or service is not denied due to the application of a statutory exclusion.

3.1. Point 1: Non-Covered Items and Services Medicare does not pay for certain items and services that are not “reasonable and necessary,” and patients are generally expected to pay for these items to the extent that those items are covered by the State Demonstrations. Medicare is prohibited from making payment for items and services not covered by the Act except for items and services covered by a Medicaid State Plan approved under Title XIX.

3.1. Point 1: Non-Covered Items and Services

An important distinction is whether an item is eligible for a Medicare benefit category. Medicare has three benefit categories: Part A, Part B, and DME. An item or service must fall clearly into one of these categories to be considered for any Medicare coverage. An item which is not covered because it does not fall into a Medicare benefit category is a Medicare non-coverable. If an item is denied as a non-coverable, the beneficiary should not be billed at all for the item or for any associated services. For example, an X-ray is ordered on a Medicare patient to check the status of healing of a broken bone. The patient believes the X-ray is covered and the provider fails to inform him that it is non-coverable. The patient then receives a bill for the X-ray. In this instance, since the patient was not informed, he should not be held liable for payment and the provider should be billed. However, if the provider informs the patient in advance and the patient signs an Advance Beneficiary Notice (ABN) agreeing to pay for the item, the patient is liable. For a small medical practice, it is often not worth the extra effort to bill the patient in such a situation when the item is non-covered. This results in losses for the practice, so it is essential for providers to check the Medicare benefit category of an item before providing it to a patient. [8][9][10][11][12][13]

Some items and services are specifically excluded from Medicare coverage by law, while others are necessary for the performance of non-covered services and are therefore also excluded from coverage. Some are supplies associated with an item of DME, for example, providing incontinence pads for a beneficiary with incontinence who is using a walker. In this instance, the incontinence pads are not covered since they are not necessary for the performance of using the walker. An item or service which is not covered is a Medicare exclusion.

3.2. Point 2: Durable Medical Equipment (DME) Coverage

The essential function of the mattress is to provide a surface for bed or mattress-bound patients to reduce discomfort from the environment, including innerspring and foam mattresses. These items are covered under the benefit category of hospital beds, an adjustable or fixed-height bed, and includes medically necessary items prescribed by a physician to relieve pain or to promote positioning which enhances functional status; improving a medical condition through elevation of the legs; or to prevent circulatory problems in the lower extremities. Historically, mattresses have been covered as a part of the hospital bed benefit because the primary function of a hospital bed is for positioning to relieve pain or to promote health and the bed is an integral part of our coverage policy for the hospital bed. Under the current NCD process, National Coverage Determinations for these types of mattresses must be revised to establish coverage.

Generally, Medicare will not pay for items or services that are not covered under the statute as a benefit. However, there are statutory exclusions from Medicare coverage for DMEPOS. If an item or service falls within a statutory exclusion, Medicare will not cover the item or service even if it is reasonable and necessary and/or it is covered as a benefit in another section of the Medicare law. One such exclusion is maintenance therapy. Effective for services performed on or after January 1, 1998, if the sole restorative function of an item is to maintain a beneficiary’s current condition or to prevent or slow further deterioration of the beneficiary’s condition, the item is excluded from coverage as DME.

4. Alternative Options for Mattress Coverage

For Medicaid enrollees, in some states durable medical equipment, like a hospital bed, may be provided for home use with prior authorization. Since coverage and provisions vary between states, it is necessary to consult with the Medicaid office with any questions regarding the mattress coverage. Unfortunately, in some states, Medicaid has very limited coverage for medical equipment and may not be able to provide a suitable mattress or any aid to it. Applicants and recipients should refer to their plan explanation and seek counsel from their doctor and Medicaid.

It is important to note that though Medicare is not capable of providing for your mattress needs, Medicaid has the potential to provide an exception to this rule. The purpose and provisions of Medicaid are organized to serve the poorest sectors of American society. Medicaid is a joint state and federal insurance program that serves primarily low-income individuals and families. Managed care is a means of providing care to Medicaid recipients while helping the state control costs. Almost all states have contracted with managed care organizations to provide services to Medicaid beneficiaries. If you are a Medicaid enrollee, the Medicaid program may pay the managed care organization to cover the cost of some medical services that the organization decides are medically necessary for you or your covered family members.

4.1. Point 1: Medicaid Coverage

As a first step, this requires that the patient has a pressure sore that has been examined and is determined to be a stage II or greater. The stage of the sore determines what type of mattress may be considered medically necessary. At present, Medicare recognizes support surfaces as either group 1 or group 2. Group 1 surfaces are defined as basic and are only covered in the treatment of a severe sequelae, while group 2 surfaces are considered for prevention and treatment and are covered if medically necessary. A stage II sore requires treatment with a group 1 surface, while a stage III or stage IV sore requires a group 2 surface. It is important to note that the decision to move forward with treatment using a group 1 surface must be reevaluated for any increase in sore severity.

Medicaid is a federal and state insurance program which may cover the cost of an alternating pressure mattress or other therapeutic type support surfaces in the home. States have the option to cover group 2 support surfaces; however, coverage of mattresses is mandatory in some states. In all cases, the individual must have a medical need for the mattress to prevent, treat, or manage a pressure sore. Medicare defines a pressure sore as a local injury to the skin/bony tissue caused by unrelieved pressure, occurring in a person receiving health care, primarily in a home or institutional setting. In making the medical necessity determination, Medicare considers the current condition of the patient, the characteristics of the mattress prescribed, and the clinical presentation of the pressure sore or recent history of pressure sore formation.

4.2. Point 2: Private Insurance Coverage

The final and most confusing aspect of this issue may be the coverage of replacement mattresses for a bed that is still owned by the patient. Under current DME regulations, a replacement mattress is covered as part of a repair to a benefit category DME item such as a hospital bed. This provision expires in 2012, but it is to be reviewed by the NCD for the replacement of certain parts of DME for clarifications on what constitutes a part replacement versus a repair versus a new item. Though it is hard to discern, it is possible that this provision may be revisited.

Step-by-step details on how the deemed purchase affects the supplier and patient can be found in Pub. 15 of the CMS website, which states that it is designed for DME suppliers who submit claims to DME MACs. At any rate, while the four-month rental and a straight purchase are both possibilities for owning the bed, it is said that to be in the best interests of the beneficiary that the bed remain a rental until it is no longer needed or Medicare is no longer being billed. So long as repair payments or payments for a new bed that provides equal or better features to the old bed stay within the 13/10 month repair ceiling, Medicare will pay these charges, and it is still considered to be part of the capped rental payment for the bed.

While the bed itself is covered under the DME program, the coverage and the types of mattresses that can be covered are a bit convoluted. Beds are covered under a capped rental option, but during the first few months of the program, Medicare discovered that beneficiaries were choosing to purchase the beds rather than rent them for differing reasons. To facilitate this, Medicare made it possible for beneficiaries to choose payments for the purchase of the bed rather than continuing to make monthly rental payments, which would be more expensive in the end. In practical terms, however, the purchase usually ends up occurring as a mere transfer of the last rental payment to ownership of the bed. Such a payment can take place if, after the first month of rental, the supplier can allow the patient to decide whether to make the transfer. After this point, the supplier has gotten what is called a deemed purchase, and payment can only be made for repairs or replacement of the bed. Step-by-step details on how the deemed purchase affects the supplier and patient can be found on the Medicare Learning Network.

Under its provisions for coverage of DME, Medicare could cover a hospital bed as a semi-electric adjustable bed if the patient’s medical condition necessitates the change in sleeping surface. In this case, the adjustable feature is what makes it a DME item since the bed can be adjusted to aid in the treatment of various medical conditions. Maintenance of a healing setting, prevention of making the patient’s condition worse, and the need for an adjustable bed to treat the condition could all be part of the rationale for coverage of the bed.

Despite the fact that Medicare itself does not cover mattresses, there may be circumstances in which you could have a mattress covered by Medicare as a piece of durable medical equipment (DME). Techniques to get a more comfortable mattress for Medicare recipients have been successful on a case-by-case basis, partially through provisions for rental or purchase of hospital beds.

References:

[1] P. G. D. A. H. Associalion and D. OH, “Subacute Care in Urban Hospitals: A Case for Urban Swingbeds,” academia.edu, . academia.edu

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[5] M. K. Schiaffino, M. Ruiz, M. Yakuta, A. Contreras, “Culturally and linguistically appropriate hospital services reduce Medicare length of stay,” Ethnicity & Health, 2020, ncbi.nlm.nih.gov. nih.gov

[6] P. Brierley-Bowers, H. Connors, et al., “The cost of medically unnecessary days due to waiting for guardianship in a state acute hospital system,” in Health Services Research: The Journal of …, 2022, journals.sagepub.com. sagepub.com

[7] M. Mitchell and T. Stratmann, “The economics of a bed shortage: certificate-of-need regulation and hospital bed utilization during the COVID-19 pandemic,” Journal of Risk and Financial Management, 2021. mdpi.com

[8] B. F. Pettingill, Jr. and F. R. Tewes, “Attorneys should understand about medicare set-aside allocations: How medicare set-aside allocation is going to be used to accelerate settlement claims in,” Clinical Medicine and Medical, 2021. clinicalmedicine.in

[9] M. Canterberry, C. L. Long, A. Bowe, et al., “Association of Health-Related Social Needs with Quality and Utilization Outcomes in a Medicare Advantage Population with Diabetes,” JAMA Network, vol. 2023. [Online]. Available: jamanetwork.com. jamanetwork.com

[10] B. N. Rome, S. Nagar, A. C. Egilman, J. Wang, et al., “Simulated Medicare drug price negotiation under the Inflation Reduction Act of 2022,” JAMA Health Forum, vol. 2023. [Online]. Available: jamanetwork.com jamanetwork.com

[11] B. Vatter, “Quality disclosure and regulation: Scoring design in medicare advantage,” Available at SSRN 4250361, 2022. aeaweb.org

[12] S. S. Hellems, A. Soni, D. Fasching, B. S. Smith, et al., “Association between health system specialty pharmacy use and health care costs among national sample of Medicare Advantage beneficiaries,” Journal of Managed Care Pharmacy, vol. 28, no. 3, pp. 262-271, 2022. [Online]. Available: jmcp.org jmcp.org

[13] C. Carey, “Sharing the burden of subsidization: Evidence on pass-through from a subsidy revision in Medicare Part D,” Journal of Public Economics, 2021. nber.org