Does Medicare Cover Durable Medical Equipment?
Yes, Medicare Part B (Medical Insurance) covers durable medical equipment (DME) considered medically necessary to treat a medical condition or injury. Examples of DME that Medicare may cover include:
- Wheelchairs and scooters
- Oxygen equipment and supplies
- Walkers, canes, and crutches
- Blood glucose monitors and test strips
- Continuous Positive Airway Pressure (CPAP) devices
- Nebulizers and nebulizer medications
- Enteral nutrition equipment and supplies
- Prosthetic devices
However, Medicare has specific coverage criteria for each type of DME, and not all DME is covered. Additionally, there may be limits on how much Medicare will pay for specific items, and patients may need to pay a portion of the cost.
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Increasing Need For Assistive and Health Monitoring Devices
Americans commonly require DME to recover from an injury or perform daily activities. In fact, about one in four U.S. adults (26%) have a disability that could necessitate the use of DME.
Medicare coverage for DME requires medical necessity and an in-network doctor’s order. Items requested merely for added convenience, such as air conditioners, toilet seats, and some disposable supplies like incontinence pads, are excluded from Medicare DME coverage.
Types of DMEs Covered By Medicare
Blood sugar meters
Blood sugar test strips
Not including white canes for the blind
If confined to your bedroom
Continuous passive motion devices
For knee injuries/surgery for 21 days
Continuous Positive Airway Pressure (CPAP) devices
As a 3-month trial, if diagnosed with obstructive sleep apnea
Home infusion services
Infusion pumps and supplies
Lancet devices and lancets
Must have Diabetes
Nebulizers & nebulizer medications
Oxygen equipment and accessories
Rentals are covered; Owners of equipment can receive coverage for systems and supplies if they have severe lung disease, low arterial blood gas levels, might improve their health with oxygen therapy, or have failed to improve through other treatments.
Pressure-reducing support surfaces
Requires doctor prescription
Wheelchairs and scooters, powered
Face-to-face examination with doctor; written prescription
What Kinds of DME Does Medicare Exclude From Coverage?
DME must be medically necessary, intended for home use, irrelevant to a well or non-injured person, and durable for at least three years to be covered by Medicare. DME excludes items that are merely convenient but not medically necessary. DME not covered by Medicare includes:
- Air conditioners
- Toilet seats
- Disposable supplies not used with approved DME
- Wheelchair ramps
- Hearing aids
Medicare Coverage For DME Types
Medicare Part A and Part B each provide distinct benefits. Under Part A, approved DME is covered as part of a stay in a hospital, skilled nursing facility, or hospice care. Part B covers DME prescribed by a Medicare-enrolled primary care physician to be used at home.
After paying their Part B deductible, Medicare recipients are responsible for 20% of the costs of the approved DME. Costs may vary depending on whether you rent or buy the equipment.
Beneficiary Eligibility Criteria
Medicare beneficiaries must meet universal eligibility requirements for DME. Generally, Part B benefits cover approved DME provided it is deemed medically necessary and prescribed by a Medicare-enrolled doctor. Beneficiaries may need to take some extra steps to get coverage for certain DME.
For example, Medicare coverage for DME includes CPAP devices, but only initially as a three-month trial if the patient is diagnosed with obstructive sleep apnea. After three months, the patient must meet in person with their doctor to discuss further Medicare coverage of this DME.
Equipment Eligibility Criteria
For a piece of equipment to be distributed to Medicare recipients, DME must be:
- Durable: The equipment must be durable enough to handle repeated use, with a minimum lifespan of three years.
- Have Medical Applications Only: DME equipment distributed by Medicare must have purely medical applications and not be used by someone who is well or uninjured.
- For Home Use Only: Medicare DME is for home use early as it is covered under Medicare Part B.
Medicare also requires both the prescribing doctor and DME supplier to be enrolled in Medicare to cover the DME. Suppliers must endure a stringent process to meet Medicare DME coverage standards.
The Competitive Bidding Program For DME
Medicare allows contractors to submit bids for these items through its competitive bidding program for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Medicare vets prospective contractors to ensure they meet Medicare standards and use their bids to set DME prices, especially in highly competitive areas.
As of January 2021, Original Medicare beneficiaries must seek competitively-bid DME for off-the-shelf items, including knee and neck braces. Beneficiaries who require a specific brand of DME must obtain a written prescription from their doctor. Contractors must provide the brand of DME requested by your doctor or work with you to find a sufficient alternative.
How Does Medicare Advantage Cover DME?
Medicare Advantage plans must provide the same coverage for doctor-prescribed, medically necessary DME as Part A and Part B. However, most Medicare Advantage plans go a step further. Many Part C plans cover DME excluded from Original Medicare, such as life alert systems, grab bars, hearing aids, and adult diapers and incontinence supplies.
These additional types of DME may require other criteria, including using only in-network doctors and suppliers and obtaining pre-approvals for DME per your individual insurance company.
Cost of Medicare Advantage Coverage For DME
While Part B premium costs are set for beneficiaries each year, and most participants qualify to waive Part A premiums, costs for privately-offered Medicare Advantage plans vary by insurer. Unlike Original Medicare, Part C plans usually include an out-of-pocket maximum, which means your deductible, copays, and out-of-pocket expenses go toward reaching the maximum and cannot exceed that amount. The percentage of DME costs paid by the beneficiary also goes toward satisfying their out-of-pocket maximum.
How Does Medicare Supplement Cover DME?
Medicare Supplement (Medigap) insurance does exactly what its name suggests: supplements Original Medicare benefits. Medigap does not include additional benefits but can help cover expenses like deductibles, copays, and coinsurance related to Part A and Part B.
Beneficiaries must be enrolled in Original Medicare to pursue Medigap insurance. They may not enroll in Medicare Advantage and Medigap at the same time. Medigap may provide additional savings to help cover the costs of DME for beneficiaries struggling to cover their percentage of the copay or coinsurance required to rent or buy the DME they need.
How to Get Durable Medical Equipment From Medicare
Beneficiaries must go through a Medicare-approved supplier to get durable medical equipment. Enrollees in Original Medicare can search through a directory of approved suppliers on Medicare.gov. If they are seeking DME through the competitive bidding program, they must ask the bidder directly for their Medicare supplier number for Medicare to cover the DME.
Medicare Advantage beneficiaries may require a slightly different process for obtaining DME. Advantage enrollees must also go through a Medicare-enrolled doctor and approved supplier for DME; however, they should consult their individual insurer for requirements and prices.
Renting vs. Purchasing Durable Medical Equipment
Medicare may require certain DME to be rented, purchased, or offer a choice between these two options. Medicare commonly offers rentals of DME, including manual or power wheelchairs and oxygen systems. Medicare tends to offer lower costs and includes repair or replacement services with rented devices.
Purchasing DME is required by Medicare for some equipment, including custom-fit prosthetics. In other cases, beneficiaries who already own DME may receive Medicare reimbursement or coverage for the supplies needed to use the equipment. Medicare coverage for DME purchased (not rented) does not include repair or replacement costs.
Replacing a Piece of Durable Medical Equipment
Replacing DME requires a new written prescription or order from a Medicare-enrolled doctor. The new order from your doctor must explain why a replacement is medically necessary. Like an initial request for DME, the replacement must come from a Medicare-approved supplier.
Medicare will only replace worn-out DME if it has been in the possession of a beneficiary for its entire lifetime. Beneficiaries requesting upgraded DME may need to pay out of pocket if it is not medically necessary. In other cases, where a special feature or upgrade is medically necessary, doctors must order Medicare to cover the item.
Appealing a Denied DME Claim
Beneficiaries may appeal a denied DME claim if they feel the equipment or supplies should be covered by Medicare. The appeals process requires multiple steps and careful documentation of Medicare paperwork and doctors’ DME prescriptions and orders.
Beneficiaries might first want to check Medicare.gov for a list of covered DME. If they still feel their claim denial was made in error, they should consult their latest Medicare Summary Notice, which details claims and expenses in three-month increments while on Medicare. Beneficiaries must submit their appeal by the deadline listed on their Medicare Summary Notice.
Original Medicare appeals require a redetermination request form to be sent to the specific agency that handles appeals for Medicare. Medicare Advantage may need to follow a slightly different protocol to appeal a claim, as per their individual insurer. Beneficiaries should include any DME documentation from Medicare-enrolled doctors or suppliers that could help their case. Most appeals return a decision within 60 days.
Putting It All Together
DME Medicare coverage is critical for beneficiaries recovering from illnesses and injuries. Medicare coverage for DME falls primarily under Part B benefits or Part A for Medicare beneficiaries undergoing hospitalization or living in a skilled nursing facility.
Medicare Advantage plans also cover DME, potentially including additional supplies and devices not covered by Original Medicare. Generally, beneficiaries enjoy affordable options to rent, purchase, or rent-to-own DME after they reach their Part B deductible or out-of-pocket maximum in an Advantage plan. Medicare may offer especially low prices on commonly used DME through its competitive bidding program.