By the Unified Savers Editorial Team
This is general information, not medical, legal or benefits advice. Coverage rules for durable medical equipment are technical, differ between Medi-Cal and Medicare, differ again inside Medicare Advantage and Medi-Cal managed care plans, and change over time. Confirm the current position with the person’s own plan and prescriber before relying on anything here, and get coverage decisions in writing.
The single most useful thing a family can learn about equipment is that coverage almost never turns on whether the item would help. It turns on which regulatory box the item sits in and whether the prescriber’s notes contain the specific findings that box requires. A hospital bed and a stair lift are both things that keep someone safe at home. One is durable medical equipment and is routinely covered. The other is a home modification and is routinely not, no matter how obviously it is needed. Families that understand this distinction stop wasting months appealing the unwinnable requests and start putting the right evidence behind the winnable ones.
What Counts as Durable Medical Equipment
Both Medicare and Medi-Cal work from a similar definition. Durable medical equipment, universally shortened to DME, is equipment that withstands repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful to someone who is not ill or injured, and is appropriate for use in the home.
Each element of that definition does work. “Withstands repeated use” is why disposable items are handled under a different benefit. “Not useful in the absence of illness” is why a stairlift, a walk-in shower or a wider doorway sits outside the definition even when a doctor recommends it, because those things are useful to anyone and are treated as improvements to a house rather than as medical equipment.
Items that typically fall inside the DME category include hospital beds and pressure-relieving mattresses, manual and power wheelchairs, scooters, walkers and rollators, patient lifts of the type usually called Hoyer lifts, commodes and bedside toilets, oxygen equipment, nebulisers, suction machines, continuous positive airway pressure devices, blood glucose monitors, and standing frames.
Items that typically fall outside it include grab rails, ramps, stair lifts, bathroom conversions, widened doorways, and most home safety improvements, along with comfort items and anything classed as convenience rather than treatment.
The one that catches everybody: shower and bath equipment
Ask any discharge planner which denial they explain most often and the answer will be bathing equipment. A shower chair or bath bench is, under long-standing Medicare policy, generally treated as a comfort or convenience item rather than as medical equipment, and it is commonly not covered. Families find this incomprehensible, because falls in the bathroom are among the most consequential events that happen to an older adult at home.
Medi-Cal’s treatment of bathing and safety equipment can be more generous than Medicare’s, and managed care plans vary. This is a category where it is worth asking specifically rather than assuming the Medicare answer applies, and where a strongly documented medical necessity, particularly after a fall or a fracture, changes the odds.
Medicare’s Route: Part B, Suppliers and the Prescriber’s Notes
For someone with Original Medicare, DME is a Part B benefit. After the annual deductible, Medicare generally pays 80 percent of the approved amount and the beneficiary is responsible for the remaining 20 percent, which is where a Medigap policy or Medi-Cal, for people who have both, does its work.
Three conditions have to be met and any one of them can sink a claim.
A prescriber must document medical necessity. The order matters far less than the clinical notes behind it. For a hospital bed, for instance, the notes need to establish why an ordinary bed will not do, in terms of a documented condition requiring positioning that a regular bed cannot achieve, or the need for traction equipment, or a requirement for the head of the bed to be elevated beyond a certain angle. A note saying the patient would be more comfortable does not satisfy that test. A note describing a specific condition, the functional limitation it produces, and why the equipment addresses it does.
The supplier must be enrolled in Medicare and must accept assignment. This is not a formality. A supplier who is not enrolled cannot bill Medicare at all, and one who does not accept assignment can charge more than the approved amount. Ask the question in those words before anything is delivered, and confirm the supplier through Medicare’s own supplier directory rather than taking the company’s word for it.
Competitive bidding may restrict which supplier you can use. For certain equipment categories in certain areas, Medicare has operated a competitive bidding programme that limits coverage to contracted suppliers. The programme’s scope has changed over time. The practical instruction is unchanged: confirm with the plan or with Medicare that the specific supplier can bill for the specific item, in your area, before delivery.
Rent or buy is decided for you
Medicare classifies items into payment categories, and much equipment is rented rather than purchased, with the rental converting to ownership after a defined period of continuous use. Power wheelchairs and some other items follow different rules. Families are frequently confused to discover they do not own a bed they have had for a year. Ask which category the item falls into and what happens at the end of the rental period, especially if a move or a change of plan is anticipated.
Medicare Advantage is a different conversation
If the person is enrolled in a Medicare Advantage plan rather than Original Medicare, the plan administers the benefit. It must cover what Original Medicare covers, but it sets its own network and its own prior authorisation rules, and it can be considerably stricter about process while being no less generous on substance. Get the plan’s DME prior authorisation requirements in writing at the start, because an item delivered outside the plan’s process can be denied on procedure alone.
Medi-Cal’s Route: Prior Authorization and the TAR
For Medi-Cal members, DME is a covered benefit and the mechanism is generally prior authorization. In fee-for-service Medi-Cal that means a Treatment Authorization Request, which providers universally call a TAR, submitted by the supplier with the prescriber’s documentation attached. In Medi-Cal managed care, the member’s plan runs its own authorisation process.
The important differences from Medicare, for a family, are these. Medi-Cal has no coinsurance for covered DME, so an approved item generally costs nothing, which is why establishing Medi-Cal eligibility is often the highest-value thing a family can do. Medi-Cal covers some categories Medicare does not, notably incontinence supplies, which are excluded from Medicare as disposable but are covered by Medi-Cal for eligible members with a documented medical condition, subject to quantity limits. And where someone has both Medicare and Medi-Cal, Medicare bills first and Medi-Cal generally picks up the coinsurance.
For members enrolled in an IHSS-adjacent Medi-Cal waiver, additional equipment and even some environmental adaptations may be available through the waiver that are not available through the standard benefit. Our guide to Medi-Cal waivers beyond IHSS covers which programmes those are.
The Boundary: Equipment Versus Modifying the House
This is where families lose the most time, so it is worth stating plainly. A patient lift that hoists someone from bed to chair is equipment and is generally covered. A ceiling track installed through the joists to run that lift on is a building alteration and generally is not. A commode is covered. Converting the bathroom so a wheelchair can enter it is not. A wheelchair is covered. The ramp that gets the wheelchair to the front door is not.
The reasoning is consistent even where the result is absurd in a particular house: the benefit buys medical equipment for a person, not improvements to a property. When the person moves, the equipment goes with them; the ramp does not.
Three things follow from that. First, do not spend months appealing a modification under a DME benefit; the denial is structural and appealing it is a losing use of scarce energy. Second, look instead at the programmes that do fund modifications, which are a different list: certain Medi-Cal home and community-based waivers, some Area Agency on Aging programmes, local housing rehabilitation funds, veterans’ grants for eligible veterans, and disease-specific charitable organisations. Our piece on IHSS and home modifications sets out how those routes work. Third, get an occupational therapy home evaluation if you can. An OT assessment, which may itself be covered when ordered by a physician, produces exactly the documentation that makes a DME request succeed, and simultaneously produces the specification a builder needs for the parts that are not covered.
When the modification work does have to be paid for privately, the practical difficulty is rarely money alone; it is that these are small, fiddly, safety-critical jobs that many contractors are not interested in quoting for, and they are precisely the jobs where poor work is dangerous. A grab rail anchored into drywall instead of a stud is worse than no grab rail, because the person now trusts it. Tegula Stone (from the same team as Unified Savers) is one way to put a written project description in front of independent contractors in your area and collect quotes without ringing round one at a time. It is a connector rather than a contractor: it does not do the work and does not vouch for anyone, so the usual checks remain yours, including verifying the licence with the California Contractors State License Board, asking the insurer directly for a current certificate of liability and workers’ compensation cover, and getting the scope in writing before anyone starts. Asking for a quote costs nothing.
Get quotes from local contractors
Making a Request That Succeeds
The pattern of successful DME requests is consistent across both programmes.
Get the clinical detail into the notes, not just the order. Ask the prescriber to record the diagnosis, the specific functional limitation, what has already been tried and why it failed, and why this particular item addresses the problem. “Patient is unable to transfer from bed to chair without two-person assistance following a hip fracture, has fallen twice during transfers, and a patient lift will permit safe single-person transfer at home” is a request with a future. “Please supply lift” is not.
Match the item to the documented need, not to the best available version. Requests fail on specification more often than on principle. A power wheelchair asked for where the notes support a manual chair gets denied in full, and the person ends up with nothing while the appeal runs, when a correctly specified manual chair would have been delivered in a fortnight.
Use a supplier who does this daily. Experienced DME suppliers know what each plan wants in the paperwork and will often work with the prescriber’s office to get it right before submission. This is the single largest practical difference between a request approved in weeks and one denied twice.
Ask for everything in writing. A verbal denial cannot be appealed. Ask for the written denial notice with the reason and the appeal rights, because the stated reason very often reveals a missing document rather than a substantive refusal.
Appeal, and appeal quickly. Both programmes have formal appeal routes with deadlines: Medicare through its multi-level appeals process, Medi-Cal through the plan’s grievance process and then a state fair hearing. Denials at first review are common and reversals on appeal are common too, particularly where the appeal supplies the clinical detail the original request omitted. Diarise the deadline from the date on the notice, not from the date you opened the envelope.
Look at borrowing while the request runs. Many communities have equipment loan closets run by independent living centres, Area Agencies on Aging, faith organisations or disease-specific charities, lending wheelchairs, commodes and walkers without charge. It is not a substitute for the benefit, but it fills the gap while the paperwork moves, and it is a route almost nobody is told about at discharge.
Frequently Asked Questions
Q: Medicare denied a hospital bed. What is the most likely reason? A: Almost always the documentation rather than the item. Hospital beds sit in a category where the clinical notes have to establish why an ordinary bed is inadequate, in terms of a defined condition requiring positioning that a standard bed cannot provide, a need for traction, or a requirement for elevation of the head of the bed beyond a specified angle. Notes recording comfort, preference or general frailty do not meet that test. Get the written denial, read the stated reason, take it back to the prescriber and ask for the specific finding to be documented from the medical record, then resubmit or appeal. Ask the supplier what they have seen approved for the same diagnosis; they deal with these decisions constantly and their input is usually free.
Q: Are incontinence supplies covered? A: Under Medicare, generally no. They are disposable, so they fall outside the durable medical equipment definition, and this is a fixed structural exclusion rather than a documentation problem. Under Medi-Cal, they generally are covered for eligible members where a medical condition is documented, subject to quantity limits and to authorisation. Because these are a substantial recurring household cost, this difference is one of the more valuable practical reasons to check whether an older adult on Medicare might also qualify for Medi-Cal, including through a share-of-cost arrangement. Ask the supplier to submit for the quantity the person actually needs, with the clinical justification, rather than accepting a default allocation.
Q: Who pays for repairs when covered equipment breaks? A: For rented equipment, maintenance and repair are generally the supplier’s responsibility for as long as the rental continues, which is one genuine advantage of the rental categories. For purchased equipment that the beneficiary now owns, Medicare can cover repairs to equipment it paid for where the repair is necessary and the equipment is still needed and not beyond its reasonable useful lifetime; replacement before that point is harder and usually requires evidence of loss, irreparable damage or a change in the person’s condition. Medi-Cal similarly covers repair with authorisation. Report a breakdown promptly and in writing; a gap in documentation between the failure and the request creates avoidable difficulty.
Q: Can we buy the equipment ourselves and get reimbursed? A: Treat the answer as no unless a plan has told you otherwise in writing beforehand. Both programmes are built around the supplier billing directly, and prior authorisation is designed to happen before delivery, not after purchase. Buying first and claiming later commonly results in no payment at all, because the process was not followed and the item was never authorised. If the need is genuinely urgent, the better routes are asking the supplier to expedite, asking the plan about an expedited authorisation where the person’s health is at risk, or borrowing from a community loan closet while the request is processed.
Q: The person has both Medicare and Medi-Cal. Which one do we ask? A: Both, in order. Medicare is the primary payer and is billed first for anything within its benefit, with Medi-Cal then generally covering the coinsurance, which is what makes dual coverage so valuable in practice. For items Medicare excludes entirely, such as incontinence supplies, the request goes to Medi-Cal on its own terms. A supplier experienced with dual-eligible members will handle this sequencing without being asked; one who is not may bill only Medicare, leave the 20 percent unbilled, and send the family an invoice for a balance Medi-Cal should have covered. If that invoice arrives, do not pay it before asking the supplier whether Medi-Cal was billed.
Q: Will accepting equipment affect eligibility for other benefits? A: Covered medical equipment supplied through Medicare or Medi-Cal is a medical benefit and is not income. It does not count as income for SSI, and it does not reduce IHSS hours by itself. What can change IHSS hours is the underlying functional picture: if equipment genuinely reduces the assistance a person needs with a given task, a subsequent reassessment may reflect that. That is not a reason to refuse equipment that makes someone safer, and the effect runs in both directions, since documented deterioration supports more hours. If a reassessment produces a reduction you disagree with, it is appealable, and our guides on appealing an IHSS hours reduction explain the route.
Q: What is a TAR and how long does it take? A: A Treatment Authorization Request is the prior authorisation document a supplier submits to fee-for-service Medi-Cal, with the prescriber’s supporting documentation attached, asking for approval before an item is provided. Members in Medi-Cal managed care go through their plan’s equivalent authorisation process instead. Timeframes vary with the plan, the completeness of the submission and whether the request is expedited on urgency grounds, and an incomplete submission that comes back for more information restarts the clock, which is the most common cause of long waits. Ask the supplier for the submission date and the reference number, and follow up on it yourself rather than assuming silence means progress.
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