Does Medicare pay for a toilet riser? Your guide to coverage and costs

According to the Centers for Disease Control and Prevention (CDC), millions of older adults fall each year, with many injuries occurring in the bathroom. This leads many seniors and their families to ask, Does Medicare pay for a toilet riser? Understanding Medicare's specific rules for durable medical equipment (DME) is crucial for managing healthcare costs and ensuring bathroom safety.

Quick Summary

Medicare typically classifies toilet risers and raised toilet seats as convenience items rather than medically necessary equipment, meaning Original Medicare does not cover them. Beneficiaries may find limited coverage through specific Medicare Advantage plans or alternative programs, so it's important to understand your options beyond Original Medicare.

Key Points

• Original Medicare Denial: Original Medicare (Parts A & B) does not cover toilet risers, as they are classified as convenience items, not medically necessary durable medical equipment (DME).

• Medicare Advantage Potential: Some Medicare Advantage (Part C) plans may offer coverage through supplemental benefits, such as over-the-counter (OTC) allowances, which can be used for bathroom safety devices.

• Commode Chair Exception: A commode chair can be covered by Original Medicare if a doctor deems it medically necessary due to the beneficiary's inability to use a regular toilet, and it can function as a raised seat.

• Investigate Alternative Funding: Options like Medicaid waiver programs, Veterans benefits, Flexible Spending Accounts (FSAs), and Health Savings Accounts (HSAs) can help pay for bathroom safety equipment.

• Out-of-Pocket Purchase: Since many basic toilet risers are affordable, paying for the item out-of-pocket is a common solution when insurance does not provide coverage.

• Consult Your Provider: It is crucial to consult your doctor and Medicare Advantage plan administrator to understand the specifics of your coverage and explore all potential options.

Original Medicare and the Durable Medical Equipment (DME) definition

Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), has specific rules for what it will cover. Part B covers certain medically necessary durable medical equipment (DME). For an item to be classified as DME, it must meet several criteria:

• It is durable, meaning it can withstand repeated use.
• It is used for a medical reason.
• It is not usually useful to someone who isn't sick or injured.
• It is used in your home.
• It has an expected lifetime of at least three years.

The case against toilet risers

Medicare generally views toilet risers and elevated toilet seats as convenience items, not medically necessary DME. While a toilet riser is used for a medical reason—to help a person with mobility issues safely use the toilet—Medicare's interpretation is that it is useful to anyone who wants a higher toilet. Because of this broad interpretation, Original Medicare denies coverage for these items. This policy extends to most other bathroom safety equipment, such as grab bars and transfer benches.

Potential coverage through Medicare Advantage plans

While Original Medicare offers a clear "no" on toilet risers, the situation is different for beneficiaries enrolled in a Medicare Advantage (Part C) plan. These plans are offered by private insurance companies approved by Medicare and are required to cover everything that Original Medicare does. However, many Medicare Advantage plans also offer supplemental benefits that Original Medicare does not.

How to get coverage with a Medicare Advantage plan

Coverage for toilet risers and other bathroom safety devices is not standard across all Medicare Advantage plans. Instead, it may be included as a supplemental benefit, often tied to over-the-counter (OTC) allowances. For example, a plan might provide a debit card with a quarterly or annual allowance for health-related items. Beneficiaries could use this allowance to purchase a toilet riser or other equipment from approved suppliers.

To determine if your Medicare Advantage plan offers this benefit, you should:

1. Contact your plan provider: Ask specifically if your plan includes an OTC allowance or coverage for durable home medical supplies.
2. Review your plan documents: Look for a list of covered supplemental benefits and a catalog of approved items.
3. Ask about restrictions: Some plans have restrictions on which suppliers you can use or a limit on the total dollar amount for these items.

Comparing coverage options: Original Medicare vs. Medicare Advantage

Feature	Original Medicare	Medicare Advantage (Part C)
Toilet Riser Coverage	None. Considered a convenience item.	Maybe. Depends on the specific plan's supplemental benefits.
Commode Chair Coverage	Yes. If medically necessary and used at home for specific reasons (e.g., cannot reach the toilet).	Yes. Must offer at least the same coverage as Original Medicare.
Grab Bar Coverage	None. Considered a convenience item.	Maybe. Some plans offer an OTC or home safety device allowance.
Supplier Network	Must use a Medicare-enrolled supplier to receive coverage for any DME.	May require you to use an in-network supplier for all covered items.
Home Modifications	None. Medicare never covers structural home modifications.	Maybe. Some special needs plans offer limited coverage for beneficiaries with chronic conditions.

What to do if Medicare doesn't cover your toilet riser

If you have Original Medicare or a Medicare Advantage plan that does not cover toilet risers, there are still options for financing these devices.

• Health Savings Accounts (HSAs) and Flexible Spending Accounts (FSAs): You can often use these pre-tax funds to pay for medical equipment, including raised toilet seats and commodes.
• Medicaid: Eligibility and coverage vary by state. Medicaid may cover bathroom safety equipment for low-income individuals, especially through special waiver programs designed to help people live at home.
• Veterans Benefits: The Department of Veterans Affairs (VA) offers specific grants and programs to help eligible veterans with home modifications and assistive devices.
• Nonprofit Organizations: Local charitable organizations, such as the Area Agency on Aging or Rebuilding Together, may offer assistance programs for seniors needing home safety modifications.
• Out-of-Pocket Purchase: Given that most basic toilet risers are relatively inexpensive, paying out-of-pocket is a common and straightforward solution.

Steps to take if you need a toilet riser

1. Talk to your doctor. A medical professional can help you determine the best type of equipment for your needs. Even if Medicare won't cover it, a doctor's prescription can provide supporting documentation for other programs or tax deductions.
2. Check your specific plan details. Call your Medicare Advantage plan provider to inquire about supplemental benefits, like OTC allowances or home safety device coverage.
3. Consider a commode chair. A bedside commode can be used as a raised toilet seat over an existing toilet. Medicare covers commode chairs under certain conditions, such as for individuals who are confined to a room without toilet facilities or cannot get to the bathroom in time. This could be a covered alternative if you meet the specific criteria.
4. Explore other funding options. Investigate state Medicaid programs, VA benefits, or local grants for home safety modifications.

The importance of assessing your home safety needs

For many seniors, aging in place safely is a top priority, and assessing bathroom safety is a critical component. While a toilet riser is one piece of the puzzle, a full safety assessment should consider other items like non-slip bath mats, sturdy grab bars installed by a professional, and accessible shower options. If you're unsure where to start, resources are available to help. The National Council on Aging offers resources on fall prevention and home safety modifications to help you identify potential risks and find solutions.

Conclusion: Navigating coverage for toilet risers

While Original Medicare does not cover the cost of toilet risers, your coverage options depend heavily on your specific insurance plan. Medicare Advantage plans may offer supplemental benefits that can help cover these expenses. If you have Original Medicare, alternatives like using a commode chair or exploring other financial assistance programs and tax deductions are available. Ultimately, the key is proactive research and communication with your healthcare providers and insurance plan administrators to ensure you have the necessary equipment for a safe home environment.

For more information on home safety and aging in place, consult authoritative resources like the National Council on Aging website.

Frequently Asked Questions

Does Medicare pay for toilet safety rails?

Original Medicare does not cover toilet safety rails. Like toilet risers, these items are considered convenience items rather than medically necessary durable medical equipment (DME).

What is the difference between a toilet riser and a commode chair?

A toilet riser is a seat that is placed on top of an existing toilet to increase its height. A commode chair is a portable, free-standing toilet that can sometimes be placed over a standard toilet and can be covered by Medicare under specific medical circumstances.

Can I use an HSA or FSA for a toilet riser?

Yes, in many cases, you can use a Health Savings Account (HSA) or Flexible Spending Account (FSA) to purchase a toilet riser or lift. These funds are set aside pre-tax for qualifying medical expenses.

Will a Medigap plan cover a toilet riser?

No, a Medigap plan will not cover a toilet riser. Medigap plans are designed to help pay for costs associated with Original Medicare-covered services (like coinsurance and deductibles) and do not provide coverage for items that Original Medicare does not cover.

Are there any exceptions where Original Medicare would cover a toilet riser?

In rare and exceptional cases, a manual or electric toilet seat lift mechanism might be considered, but a standard raised toilet seat or riser is not covered. A covered commode chair might serve a similar purpose.

How can I find out if my Medicare Advantage plan covers a toilet riser?

You should contact your plan's customer service directly and ask about supplemental benefits for durable home medical equipment or over-the-counter (OTC) allowances. You can also review your Evidence of Coverage document.

Does Medicaid cover toilet risers?

Possibly. Medicaid policies vary significantly by state. Some state Medicaid programs, particularly through Home and Community-Based Services (HCBS) waiver programs, may provide coverage for home safety modifications or equipment.