Medicare covers durable medical equipment (DME) when it is medically necessary and prescribed by a doctor for use in the home. Covered DME includes items such as wheelchairs, walkers, hospital beds, oxygen equipment, and CPAP machines. To qualify, the equipment must be durable, used for a medical reason, not usually useful to someone who isn’t sick or injured, and appropriate for use in the home. Medicare Part B typically covers 80% of the approved cost after the annual deductible is met, while the patient is responsible for the remaining 20%. It’s important to use a Medicare-approved supplier to ensure coverage.
Medigap Seminars Insurance Agency Reviews.
Key Takeaways in DME for Medicare
Durable Medical Equipment (DME) is a category of medical devices or equipment that is prescribed by a healthcare provider and is intended for long-term use.
Medicare Part B covers medically necessary DME if it meets other certain criteria. Medicare coverage works in different ways for every equipment type.
Make sure to get a Medicare-enrolled doctor, and your equipment supplier must also be Medicare-approved. The DME supplier must have a Medicare supplier number and accept assignment in order to get Medicare coverage for DME. It means they can charge you only the Medicare‑approved amount. Choosing suppliers who bill Medicare is crucial to minimize out-of-pocket costs and avoid potential additional expenses.
Medicare Advantage plans coverage of DME varies depending on the specific plan. Check with your plan provider about Medicare benefits for DME.
What Is Durable Medical Equipment (DME)?
DME is reusable medical equipment like walkers, wheelchairs, crutches, oxygen tanks, nebulizers, and other medical devices prescribed by your primary care provider.
Durable medical equipment items are defined as equipment that meets these criteria, and a complete list can be found on the official Medicare website:
Durable (can withstand repeated use)
Used for a medical reason
Typically only useful to someone who is sick or injured
Used in your home (must be appropriate for use in a home setting, which means it must be able to be easily transported and used by individuals or their caregivers)
Expected to last at least 3 years
However, certain kinds of equipment are not covered by Medicare, such as items intended solely for convenience or disposable items.
Medicare Part B covers various prosthetics and orthotics, including artificial legs and arms, as well as semi-rigid leg braces.
Most Common Medicare DME Items
Some of the most common Medicare DME items under Medicare Part B include:
Hospital beds
Wheelchairs
Mobility scooters
Oxygen equipment, including oxygen concentrators and tanks
Continuous Positive Airway Pressure (CPAP) devices for sleep apnea treatment
Nebulizers and inhalation drugs
Walkers, canes, and crutches
Enteral nutrition equipment, including feeding pumps and supplies
Home dialysis equipment and supplies
Artificial legs
Prosthetic devices such as artificial legs, arms, and eyes. Medicare also covers other types of equipment and associated prescription medications.
Does Medicare Cover Durable Medical Equipment?
Yes, Original Medicare covers DME. If you have Medicare Part B medical insurance, you will have your durable medical equipment covered under Medicare Part B as long as it’s deemed medically necessary by a doctor’s prescription.
Medicare covers medications necessary for using certain types of DME, such as nebulizers and diabetes testing supplies.
Medicare coverage for DME is contingent on meeting the following conditions: the equipment must be medically necessary, prescribed by a healthcare provider, and obtained from a Medicare-approved supplier.
There are different ways Medicare covers different types of durable medical equipment, according to Medicare guidelines and medical purpose.
Depending on the type of equipment:
You may need to rent the equipment
You may need to buy the equipment
You may be able to choose whether to rent or buy the equipment.
Remember, Medicare covers your DME only if your doctors and DME suppliers are enrolled in Medicare and are Medicare-approved.
For Medicare coverage, the DME supplier must also accept assignment (which means, they can charge you only the Medicare‑approved amount).
When Does Medicare Cover Durable Medical Equipment?
If a health care provider prescribes necessary durable medical equipment (DME) for you to use in your home, Medicare Part B will cover it. Health care providers include a doctor, nurse practitioner, physician assistant, or clinical nurse specialist.
If you are receiving care in a hospital or nursing home, it does not qualify as your “home” for Medicare coverage purposes. However, if you are in a long-term care facility, it can qualify as your home. Then Medicare pays for the DME covered.
Remember that if you are in a skilled nursing facility as part of your stay covered by Medicare Part A, that facility is responsible for providing any DME you need while you’re in the facility for up to 100 days.
What Type of Durable Medical Equipment is Medicare-covered equipment?
Medicare covers a wide range of durable medical equipment that is considered medically necessary to treat or manage a medical condition or injury, alongside certain prescription medications.
Some of the types of DME that Medicare covers include:
Mobility aids: walkers, rollators, canes, crutches, manual wheelchairs, power wheelchairs, and mobility scooters.
Medical supplies: blood sugar monitors and test strips, blood sugar monitors, continuous glucose monitors, lancets, syringes, insulin pumps, diabetes self-testing equipment, and other devices
Respiratory equipment: oxygen equipment, including oxygen concentrators and tanks, air conditioners, continuous positive airway pressure (CPAP) devices for sleep apnea treatment, nebulizer medications oxygen equipment, and inhalation drugs.
Home dialysis equipment and supplies: dialysis machines, supplies, and equipment necessary to perform hemodialysis or peritoneal dialysis at home.
Hospital beds and accessories: adjustable hospital beds, bed rails, and overbed tables.
Pressure-reducing beds, mattresses, and mattress overlays used to prevent bed sores
Prosthetic and orthotic items: artificial limbs, leg, arm, back, and neck braces, and other prosthetic devices.
Orthotic devices such as leg, arm, back, and neck braces.
Ostomy supplies: ostomy bags, pouches, and other supplies for ostomy surgery patients.
Enteral nutrition equipment: feeding pumps, supplies, and formula for individuals who cannot consume food orally.
Infusion pumps and supplies (when necessary to administer certain drugs)
Oxygen equipment and accessories
Patient lifts to lift you from a bed or wheelchair ramps
Traction equipment.
Most items not primarily intended for home use, convenience, or comfort are excluded from Medicare coverage.
Keep in mind that durable medical equipment Medicare covers may vary according to the specific guidelines for coverage of each DME item.
Also, there may be limits on the quantity of durable medical equipment covered by Medicare that it covers and Medicare beneficiaries may be responsible for sharing the cost, such as paying as a co-payment or deductible.
How Do I Get Durable Medical Equipment Approved By Medicare?
To receive coverage for durable medical equipment in your home, your healthcare provider, such as a doctor, nurse practitioner, physician assistant, or other health care provider, must prescribe the specific type of equipment you require by completing an order.
Sometimes, Medicare may also require additional documentation from your doctor to confirm your medical need for durable medical equipment. Your supplier will work with your doctor to ensure that all necessary information is submitted to Medicare. If anything changes regarding your needs or medical condition, your doctor will have to complete and submit a new, updated order.
The important point here is that Medicare Part B only covers DME if you obtain it from a supplier who is covered by Medicare and if the service meets specific criteria to qualify for Medicare reimbursement. Meaning, the DME supplier has been enrolled in and approved by Medicare, and has a Medicare supplier number.
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program
If you reside in or visit a competitive bidding area and require an off-the-shelf back or knee brace that’s part of the DMEPOS Competitive Bidding Program, you will have to use specific suppliers (“contract suppliers,”) in order for Medicare to cover them.
How Do I Get a Wheelchair or Power Scooters Through Medicare?
For a power wheelchair or scooter to be covered by Medicare, your health care provider prescribes it as medically necessary for you to use it at home, similar to back and neck braces.
A power wheelchair or scooter that you only need and use outside of the home won’t be covered by Medicare.
The following requirements also have to be met:
You have limited mobility
Your health condition causes significant difficulty moving around in your home
You can’t do daily activities like bathing, dressing, getting in or out of a bed or chair, or using the bathroom even with the help of a cane, crutch, or walker
You can safely operate and get on and off the wheelchair or scooter, or have someone with you who can always help you safely use the device
The doctor and the supplier both accept Medicare
Your doctor or supplier has visited your home and confirmed that you can use the equipment at home (for example, it can fit through doorways in your home and isn’t blocked by floor surfaces or things in its path).
How Do I Replace DME That Was Lost or Destroyed in a Disaster? Does Medicare Pay for That?
If you used Original Medicare to cover DME it will cover equipment and supplies lost or damaged due to an emergency or disaster:
In most cases, Medicare will cover the cost to repair or replace your equipment or supplies, but only when you get them from Medicare-approved suppliers.
In general, Medicare will also cover the cost of loaned equipment for certain items (like wheelchairs) while your equipment is being repaired.
What If I Have a Medicare Advantage Plan?
If you have a Medicare Advantage Plan or other Medicare health plan, you must contact them to see how your plan offers or replaces DME supplies lost or damaged in an emergency or disaster.
Medicare Advantage plans may require you to obtain DME from suppliers within the plan’s network to ensure coverage.
If you have a Medicare Advantage Plan (Part C), your plan must cover all of the same durable medical equipment (DME) services and items that Original Medicare (Part A and Part B) covers, but may also have a specific plan’s network that must be adhered to.
Some Medicare Advantage plans may have a network of preferred suppliers that you must use to obtain DME, such as incontinence pads while others may allow you to use any Medicare-approved supplier. Your plan may also have different cost-sharing requirements, such as deductibles, copayments, or coinsurance, for DME than Original Medicare.
Do Medigap Plans Cover DME?
If Medicare covers your DME, the Medigap plan will pay its portion of the approved amount for medicare covered equipment . The percentage of DME coverage depends on the Medigap plan.
Don’t hesitate to reach out to us if you have more questions about medical equipment or another Medicare topic! We’re happy to help you find Medicare coverage answers!
Sources:
https://www.medicare.gov/media/publication/11045-medicare-coverage-of-dme-and-other-devices.pdf
https://www.medicare.gov/publications/11046-medicare-coverage-of-wheelchairs-scooters.pdf
https://www.medicare.gov/coverage/durable-medical-equipment-dme-coverage
