If you or a loved one is struggling with balance or mobility, a shower chair is not just a “convenience”—it is a safety essential. A simple slip in the bathroom can lead to hospitalizations that no one wants.
However, when you look at the price tag of high-quality bathroom safety equipment, the first question is almost always: “Will my insurance pay for this?”
If you have New York Medicaid, the answer is yes, but with strict conditions.
The Big Difference: Medicare vs. Medicaid
Before we dive into New York specific rules, it is vital to understand a common confusion.
- Medicare (Federal): generally does NOT cover shower chairs. They classify them as “environmental convenience items” rather than medical equipment.
- Medicaid (New York State): DOES cover shower chairs, but only if you can prove they are “medically necessary.”
This means if you have “dual eligibility” (both Medicare and Medicaid), you will likely be relying on your Medicaid benefit to get this item covered.
NY Medicaid Rules for Shower Chairs
New York Medicaid classifies shower chairs under Durable Medical Equipment (DME). To get one covered, you must meet specific criteria outlined in the state’s DME fee schedule.
- The “Medical Necessity” Requirement
You cannot simply ask for a chair because you are tired of standing. Your doctor must document that the patient has a specific medical condition that makes showering without a chair dangerous or impossible. Common qualifying reasons include:
- Extreme weakness or high risk of falls.
- Inability to stand for more than a few minutes due to heart or respiratory issues.
- Poor balance or vertigo.
- Recent surgery (like hip or knee replacement) requiring restricted movement.
- Recent surgery (like hip or knee replacement) requiring restricted movement.
- The Specific Codes
When your doctor writes a prescription (known as a “fiscal order” in NY Medicaid terms), they cannot just scribble “shower chair.” They should ideally use the correct medical codes.
- HCPCS Code E0240: Standard Bath/Shower Chair (with or without wheels).
- HCPCS Code E0247/E0248: Transfer Bench (for those who cannot step over a bathtub wall).
- HCPCS Code E0247/E0248: Transfer Bench (for those who cannot step over a bathtub wall).
- Prior Approval (The “PA” Hurdle)
Here is the tricky part. In the New York Medicaid fee schedule, Code E0240 often carries a “PA” indicator. This stands for Prior Approval.
- This means your DME supplier (like us) cannot just hand you the chair and bill Medicaid later.
- We must submit a request to the Department of Health first, proving why you need it.
- Note for Managed Care Patients: If you have a Medicaid Managed Care plan (like Fidelis, Healthfirst, or UnitedHealthcare Community Plan), they have their own internal authorization teams. They often approve these items faster than strict Fee-for-Service Medicaid, provided the doctor’s note is strong.
Step-by-Step: How to Get Your Shower Chair Covered
If you want to use your shower chair insurance coverage, follow this checklist to ensure the process goes smoothly.
Step 1: Visit Your Doctor
You need a face-to-face visit. Tell your doctor you are having difficulty bathing safely. Ask for a prescription for a “Shower Chair” (Code E0240) or “Transfer Bench” (Code E0247).
- Crucial Tip: Ask the doctor to include a diagnosis code (ICD-10) on the prescription that explains why you need it (e.g., “Osteoarthritis,” “History of Falls,” “Gait Abnormality”).
Step 2: Find an Enrolled DME Provider
Not every pharmacy or medical supply store accepts NY Medicaid. You must find an enrolled provider.
- Alfa Healthcare Supply Inc. is experienced in handling DME claims. We can review your prescription to see if it meets the state’s strict formatting rules.
Step 3: The Waiting Game (Prior Approval)
Once you bring us the prescription and your Medicaid card, we submit the paperwork.
- Timeframe: Approval can take anywhere from a few days (for Managed Care) to a few weeks (for straight Medicaid).
- Frequency Limit: NY Medicaid typically covers one shower chair every 5 years. If you received one 3 years ago and it broke, getting a new one covered will be very difficult without proof of “irreparable damage” or a change in your medical condition.
What If I Get Denied?
Denials usually happen for two reasons:
- “Convenience” Ruling: The state decides you could shower without it, and you just want one. (Solution: Your doctor needs to write a stronger letter of medical necessity).
- Same or Similar Equipment: You already received a similar item (like a commode that can go in the shower) recently.
The "Out-of-Pocket" Option
Because the Prior Approval process can be slow, many families choose to purchase a shower chair out-of-pocket to ensure safety immediately.
- Basic shower chairs are often affordable (ranging from $40–$80).
- Buying one privately allows you to choose a premium model (like one with padded seats or a higher weight capacity) that Medicaid might not cover.
Need Help Navigating the Rules?
At Alfa Healthcare Supply Inc., we know that Medicaid NY DME coverage rules are confusing. We are here to help you understand your benefits and find the right equipment to keep you safe.
Do not wait for a fall to make your bathroom safe. Contact us today to discuss your options for shower chairs and transfer benches.
