Will Medicare Pay for a Geri Chair? A Definitive Guide to Coverage

With millions of older adults experiencing mobility challenges, understanding how health coverage works is essential. For those with limited mobility, a Geri chair offers comfort and support, but will Medicare pay for a Geri chair? The answer is nuanced and depends on specific medical requirements.

Quick Summary

Medicare typically covers the seat-lift mechanism of a lift chair (often referred to as a Geri chair) under Part B if deemed medically necessary by a physician for use in the home, but will not cover the chair's frame or upholstery.

Key Points

• Limited Coverage: Medicare typically only pays for the motorized lift mechanism of a Geri chair under Part B, not the entire chair itself.

• Medical Necessity is Key: To qualify for coverage, a physician must document a medical need for the lift mechanism, such as severe arthritis or a neuromuscular disease.

• Specific Requirements: You must be unable to stand from a standard chair but still able to walk with or without assistance once upright.

• Know Your Costs: Expect to pay your Part B deductible, a 20% coinsurance for the lift mechanism, and the full cost of the chair's frame and upholstery.

• Authorized Supplier: The Geri chair must be purchased or rented from a Medicare-enrolled supplier who accepts assignment.

• Home Use Only: The equipment must be for use in your home and not in a long-term care facility or hospital.

Understanding the Basics of Medicare and DME

Medicare Part B covers medically necessary durable medical equipment (DME), which includes items like wheelchairs, hospital beds, and other equipment that serve a medical purpose and are used in the home. However, not all equipment is covered equally, and strict criteria must be met before approval. The key to understanding coverage for a Geri chair lies in distinguishing between the furniture part of the chair and its specific medical features, namely the seat-lift mechanism.

The Crucial Distinction: Geri Chair vs. Lift Mechanism

Geri chairs, also known as medical recliners or geriatric chairs, are designed to provide extra support and comfort for individuals with mobility challenges. Unlike standard recliners, many Geri chairs include special features such as wheels for transport, adjustable positions, and enhanced cushioning. A motorized lift chair is a specific type of Geri chair that contains an electric lifting mechanism to help a person move from a sitting to a standing position.

It is this motorized seat-lift mechanism that Medicare considers DME. The rest of the chair, including the frame, fabric, cushions, and other accessories, is considered furniture and is not covered. This means Medicare may help pay for 80% of the Medicare-approved amount for the lifting mechanism after the Part B deductible is met, but you will be responsible for the remaining 20% plus the full cost of the chair's other components.

Qualifying for Medicare Coverage

To get Medicare to pay for a Geri chair's lift mechanism, you must meet specific medical and procedural requirements. Simply wanting the chair for comfort is not enough; a physician must deem it medically necessary. Here are the common criteria:

• Doctor's Prescription: You must have a written prescription from a Medicare-enrolled doctor or healthcare provider. This prescription must state that the lift mechanism is medically necessary to treat your condition.
• Face-to-Face Examination: A face-to-face visit with your doctor is required. During this appointment, the doctor will assess your condition and document the medical necessity of the equipment.
• Qualifying Medical Conditions: The primary requirement is that you have severe arthritis of the hip or knee, or a neuromuscular disease, that prevents you from standing up from a standard chair on your own.
• Home Use: The equipment must be suitable for use in your home. Your doctor or DME supplier may need to confirm that you can use the equipment effectively within your living space.
• Maintain Mobility: You must be able to walk once you are in a standing position, even if you need a walker or cane for assistance. The lift chair's purpose is to help you stand, not to replace mobility.
• Non-Institutional Setting: You cannot be a resident of a skilled nursing facility, hospital, or hospice when applying for coverage.
• Medicare-Enrolled Supplier: You must obtain the lift chair from a supplier who is enrolled in Medicare and accepts assignment to ensure Medicare will pay its portion.

Step-by-Step Guide to Getting a Covered Geri Chair

1. Consult Your Doctor: Discuss your mobility issues with your physician. They will perform an evaluation to determine if a lift chair is medically necessary for your condition.
2. Obtain Documentation: Your doctor will provide a prescription and fill out the necessary forms, such as a Certificate of Medical Necessity (CMS-849), which details your condition and why the lift mechanism is required.
3. Find an Approved Supplier: Use the Medicare.gov supplier directory or call 1-800-MEDICARE to find a Medicare-enrolled DME supplier in your area who accepts assignment.
4. Submit Your Claim: The supplier will submit the claim to Medicare for the seat-lift mechanism. You should receive a decision letter regarding your coverage. It is vital to check with your specific plan, especially if you have a Medicare Advantage plan, as requirements and network rules may vary.

Costs and Financial Responsibilities

While Medicare covers 80% of the approved amount for the lift mechanism, the patient is responsible for several costs:

• Part B Deductible: You must meet your annual Part B deductible before Medicare begins its payments.
• 20% Coinsurance: You are responsible for 20% of the Medicare-approved cost of the lift mechanism.
• Cost of the Chair: The entire expense for the chair's frame, upholstery, and any non-medical accessories is your responsibility. This can vary widely depending on the model and features selected.

Comparison: Geri Chair vs. Wheelchair

Feature	Geri Chair with Lift Mechanism	Standard Wheelchair (Manual/Power)
Primary Function	Assists with sitting/standing; provides supportive seating for extended periods.	Provides mobility for individuals unable to walk or with very limited mobility.
Medicare Coverage	Covers the motorized lift mechanism, not the chair's frame, under Part B.	Covers the entire device as DME under Part B.
Qualifying Conditions	Severe arthritis of hip/knee, or neuromuscular disease impacting standing.	Inability to move around the home, even with assistive devices like canes or walkers.
Out-of-Pocket Costs	20% coinsurance for lift mechanism + 100% of chair frame/accessories.	20% coinsurance for the total approved device cost.
Use Setting	Primarily for stationary use in the home, aiding with transfers.	For general home mobility and movement.
Mobility Requirements	User must be able to walk independently or with assistance after standing.	User has limited or no ability to walk, making it unsuitable for a lift chair.

The Rental vs. Purchase Decision

For some types of DME, Medicare gives you the option to rent or purchase. For a lift mechanism, the decision is generally dictated by Medicare's rules, which may require a rental period first. Always discuss this with your supplier, as the terms and total cost can vary. Some Medicare Advantage (Part C) plans may also have their own rules regarding rental and purchase.

Appealing a Denial

If your claim for a lift chair is denied, you have the right to appeal the decision. Start by reviewing the Medicare Summary Notice (MSN) for instructions on how to file an appeal. Gathering additional documentation from your doctor that supports the medical necessity of the equipment can be crucial to a successful appeal.

The Final Takeaway

Determining if Medicare will pay for a Geri chair is not straightforward, as coverage is limited to the mechanical lifting component. For those who meet the specific medical necessity criteria and follow the correct procedures, Medicare can provide significant financial relief for the most expensive part of the equipment. However, patients must be prepared for out-of-pocket costs related to the furniture portion and coinsurance. Always start with a discussion with your doctor and an authorized Medicare supplier to navigate the process effectively. For more details on Medicare's DME coverage rules, visit the official Medicare website at https://www.medicare.gov/publications/11045-medicare-coverage-of-dme-and-other-devices.pdf.

Frequently Asked Questions

What is the difference between a Geri chair and a standard lift chair?

A Geri chair (or geriatric chair) is a broad term for a supportive medical recliner, often with wheels for easy transport. A lift chair is a specific type of Geri chair equipped with a motorized mechanism to assist in rising and lowering, and it is this mechanism that may be covered by Medicare.

Will Medicare cover the entire cost of a Geri chair?

No, Medicare will not cover the entire cost. It only covers 80% of the Medicare-approved amount for the motorized seat-lift mechanism, and you are responsible for your deductible, the 20% coinsurance, and the full cost of the chair's non-medical components.

What medical conditions are required for Medicare coverage?

To qualify, you must have severe arthritis of the hip or knee, or a neuromuscular disease, that prevents you from rising from a standard chair independently. You must also be able to walk once standing.

Does a Medicare Advantage (Part C) plan cover Geri chairs differently?

Medicare Advantage plans are required to offer at least the same level of coverage as Original Medicare. However, they may have different cost structures, network rules for suppliers, or require prior authorization, so you should always check directly with your plan provider.

Can I get coverage if I live in a nursing home or assisted living facility?

Medicare will not cover the cost of a lift mechanism if you are a resident of a skilled nursing facility, hospital, or hospice, as these facilities are typically responsible for providing such equipment.

What happens if my claim for a Geri chair is denied?

If your claim is denied, you have the right to appeal the decision. You can find instructions on how to appeal on your Medicare Summary Notice (MSN) and should work with your doctor to provide additional documentation supporting your medical need.

Is it possible to rent a Geri chair through Medicare?

Yes, depending on the item, Medicare may cover the rental of DME. For a lift mechanism, rental is often the initial route. After a certain period, you may have the option to purchase it. Your supplier can provide details on the specific terms.