Does Medicare Pay for Toilet Risers for Seniors? What You Need to Know

According to the Centers for Medicare & Medicaid Services (CMS), most equipment designed to make a bathroom safer, like raised toilet seats, is not considered “primarily medical in nature”. This means the answer to does Medicare pay for toilet risers for seniors? is generally no, especially under Original Medicare. However, some Medicare Advantage plans offer supplemental benefits that may provide coverage.

Quick Summary

Original Medicare does not cover toilet risers because they are considered convenience items, not medically necessary durable medical equipment. This article examines Medicare's strict coverage rules for bathroom safety devices and explores coverage alternatives offered by Medicare Advantage plans, Medicaid, and other programs.

Key Points

• Original Medicare Does Not Cover Toilet Risers: Original Medicare (Part A and B) classifies toilet risers as non-covered convenience items, not medically necessary durable medical equipment (DME).

• Medicare Advantage Plans May Offer Supplemental Benefits: Private Medicare Advantage (Part C) plans sometimes provide supplemental coverage for bathroom safety equipment through OTC allowances or flex cards, but coverage varies by plan.

• Medicare Covers Bedside Commodes with Restrictions: A commode chair may be covered under Medicare Part B if prescribed for a beneficiary confined to a room without easy access to a toilet. It is not covered if simply used as a raised toilet seat.

• Medicaid and VA Offer Alternative Funding: Depending on the state, Medicaid may cover toilet risers for low-income seniors. Veterans with disabilities may receive funding through specific VA grants for home modifications.

• FSA and HSA Funds are Eligible for Purchase: Individuals with Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs) can use these tax-advantaged funds to pay for elevated toilet seats.

Original Medicare Coverage for Bathroom Safety

When it comes to coverage for Durable Medical Equipment (DME), Original Medicare (Part A and Part B) follows very specific guidelines. For an item to be covered, it must be considered medically necessary for the diagnosis or treatment of an illness or injury, be able to withstand repeated use, and be appropriate for home use. While a toilet riser might seem medically necessary for a senior with mobility issues, Medicare classifies these as personal convenience items rather than DME.

Why toilet risers are typically not covered

• Considered a convenience item: CMS policy explicitly states that raised toilet seats (the billing code E0244) are noncovered because they are not primarily medical in nature.
• Doesn't meet DME criteria: Unlike items like walkers or hospital beds, toilet risers are not considered medical equipment that is primarily and customarily needed for a medical purpose.

The difference with commode chairs

In contrast, Medicare Part B may cover a bedside commode, which is a portable toilet, under specific conditions. A commode chair is covered as durable medical equipment if the doctor prescribes it for a person who is confined to a room and unable to use the standard bathroom toilet. However, if the commode is used only as a raised toilet seat by placing it over the toilet, Medicare will not cover it.

Potential Coverage with Medicare Advantage (Part C)

Medicare Advantage plans are private insurance plans that contract with Medicare to provide Part A and Part B benefits. Unlike Original Medicare, these plans can offer additional, or supplemental, benefits that may include coverage for bathroom safety items.

Exploring supplemental benefits

Some Medicare Advantage plans may offer:

• Over-the-counter (OTC) benefits: Certain plans provide a quarterly or annual allowance to spend on OTC health-related items, including some bathroom safety devices. This can sometimes be used for raised toilet seats, but coverage varies greatly by plan.
• Flex cards: Some plans issue prepaid debit cards, known as flex cards, that can be used for health-related purchases, which might include assistive devices.
• Special needs plans: For individuals with qualifying chronic health conditions, some special needs plans (a type of Medicare Advantage plan) might offer coverage for bathroom safety devices.

To find out if a specific Medicare Advantage plan offers coverage, a beneficiary needs to contact the plan directly and review its benefits package.

Alternatives to Medicare for Funding Toilet Risers

Since direct Medicare coverage is unlikely, seniors have several alternative funding options to explore.

Medicaid

Medicaid, a joint federal and state program for low-income individuals, may cover toilet risers under certain state programs. Coverage depends on the state's specific rules, which may consider bath and toilet equipment a covered service if medically necessary. Eligibility requirements and specific covered items can vary significantly by state.

Veterans Affairs (VA) Benefits

Veterans with service-related disabilities may be eligible for benefits through the VA to cover medically necessary home modifications and assistive devices. The VA provides housing grants, including the Home Improvements and Structural Alterations (HISA) grant, which can fund accessibility improvements in bathrooms. The process requires working with a VA representative or doctor.

FSA or HSA Funds

For those who have a Flexible Spending Account (FSA) or a Health Savings Account (HSA), elevated toilet seats are considered eligible expenses. These funds can be used to purchase the equipment tax-free.

Non-profit and charitable organizations

Some non-profit organizations, like Rebuilding Together, provide home modifications for eligible low-income seniors. These services may include installing bathroom safety equipment. Seniors can also check with local Area Agencies on Aging for resources.

Comparison: Coverage for Bathroom Safety Devices

Feature	Original Medicare (Part A & B)	Medicare Advantage (Part C)	Medicaid (State-Specific)	VA Benefits	FSA/HSA	Other Resources
Toilet Riser	No, considered a convenience item.	Potential coverage via supplemental OTC or flex card benefits.	Possible, depending on state and medical necessity rules.	Possible, through specific grants like HISA for veterans.	Yes, eligible expense for tax-free purchase.	Some non-profits may assist with installation.
Bedside Commode	Yes, if medically necessary and prescribed for a person confined to a room without toilet access.	Yes, covers at least what Original Medicare does; may have different network rules.	Possible, depending on state requirements and medical necessity.	Yes, if deemed medically necessary.	Yes, eligible expense.	N/A
Grab Bars	No, considered a home modification/convenience item.	Possible via supplemental benefits for certain plans and chronic conditions.	Possible, varies by state.	Yes, through grants for eligible veterans.	Yes, eligible expense.	Home modification grants, non-profits.
Shower Chair	No, considered a convenience item.	Possible via supplemental OTC benefits; varies by plan.	Possible, depends on state and medical necessity.	Possible, depends on medical need and grant approval.	Yes, eligible expense.	Home modification grants, non-profits.

How to Proceed if You Need a Toilet Riser

1. Consult with a doctor: Discuss your mobility issues and the medical need for a raised toilet seat or alternative. A physician's prescription is a prerequisite for any potential coverage, even if Medicare does not ultimately cover it.
2. Review your plan: If you have a Medicare Advantage plan, contact your provider directly to inquire about supplemental benefits for bathroom safety equipment. Ask specifically about OTC allowances or flex card options.
3. Explore alternative funding: Look into state-specific Medicaid programs, especially if you have low income. Veterans should consult with the VA for potential grant eligibility.
4. Use FSA/HSA funds: If available, use a flexible spending or health savings account to purchase the equipment tax-free.
5. Consider a commode: If your mobility issues confine you to a room, a bedside commode covered by Original Medicare may be an option. Your doctor will need to prescribe it based on this specific need.

Conclusion

While Original Medicare does not pay for toilet risers, classifying them as convenience items, beneficiaries are not without options. Medicare Advantage plans may offer supplemental benefits that can help cover the cost. Other avenues for financial assistance include Medicaid, VA benefits for veterans, and tax-advantaged FSA/HSA accounts. For those with severe mobility limitations, a bedside commode might be a covered alternative under Original Medicare if specific medical necessity criteria are met. Understanding the differences in coverage across these programs is crucial for finding the right solution for safe and accessible bathing. For additional details on Medicare's Durable Medical Equipment guidelines, you can visit the official CMS website at https://www.cms.gov/.

Frequently Asked Questions

Will Original Medicare pay for a toilet riser for a senior?

No, Original Medicare does not pay for toilet risers for seniors. Medicare classifies them as convenience items and not medically necessary Durable Medical Equipment (DME) under its Part B coverage rules.

Does a Medicare Advantage plan cover toilet risers?

A Medicare Advantage plan may cover toilet risers, but coverage is not guaranteed. Some plans include supplemental benefits like over-the-counter (OTC) allowances or flex card benefits that can be used for certain bathroom safety items.

Can a doctor's prescription help get a toilet riser covered?

While a prescription from a doctor is required for any DME coverage, it does not guarantee that Medicare will cover a toilet riser. Because Medicare explicitly excludes raised toilet seats, a prescription will not change this policy for Original Medicare.

What is the difference between Medicare covering a commode versus a toilet riser?

Medicare may cover a bedside commode if a person is confined to a room and cannot access the toilet. However, if the commode is used over a toilet simply as a raised seat, it will not be covered. A toilet riser is never covered by Original Medicare because it is considered a convenience item.

Can I use my FSA or HSA to pay for a toilet riser?

Yes, elevated toilet seats and risers are considered eligible expenses for reimbursement with a Flexible Spending Account (FSA) or a Health Savings Account (HSA). These funds can be used for this purchase tax-free.

Does Medicaid provide coverage for toilet risers?

Yes, Medicaid coverage for toilet risers is possible, but it depends on the specific state program and its rules. Some states include bath and toilet equipment as covered items for eligible, low-income members if deemed medically necessary.

Are there other options for financial help for bathroom safety equipment?

Besides Medicaid and some Medicare Advantage plans, veterans with service-related disabilities can explore VA benefits, such as grants for home modifications. Some charitable organizations may also provide assistance.