Does Medicare Cover Durable Medical Equipment?
Medicare Coverage of Durable Equipment: Yes, Medicare covers DME, however, coverage depends on the type of Medicare coverage that you have. There are several different types of Medicare coverage's and each one treats DME coverage differently. Keep reading for all the details or call us at 920-545-4884
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What is Durable Medical Equipment?
Durable medical equipment, or DME, is any type of equipment that provides a therapeutic benefit to a person in need as the result of a specific illness or medical condition.
DME characteristics include:
- Primarily used to serve a medical purpose
- Useful to a person only if they have an illness or an injury
- It is prescribed by a physician
- Intended for repeated use and is reusable
- Can be used in a person’s home
How Does Medicare Cover Durable Equipment?
Part A Coverage:
Part A covers DME for patient who are in a hospital or skilled nursing facility. The equipment must be ordered by a physician, indicating that it is medically necessary, and it must be purchased through an approved Medicare DME supplier.
After your part A deductible is met, you will be responsible for 20% of the allowed amount on the specific piece of medical equipment that you require. This 20% coinsurance will either be paid out of your pocket or may be picked up by your WI Medicare supplemental policy, if you have one.
Part B Coverage:
Part B coverage will pay for equipment to be used in the beneficiary’s home. This does not mean that the beneficiary has to be confined to their home in order to receive coverage for this benefit. Part B also considers an assisted living facility to be a person’s home, however a nursing home is not.
Similarly to Part A., Part B covers 80% of medical equipment after the deductible is met. This is applicable if the equipment is prescribed by a physician and purchased through an approved Medicare retailer. The remaining 20% coinsurance of the allowed amount of the equipment is the responsibility of the beneficiary to cover. Again, this can be covered with a supplemental policy or paid out of pocket.
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Part C refers to WI Medicare Advantage plans. These plans are a combination of parts A and B and are sold through private insurances, not the government.
Part C plans are required to offer at least the same DME coverage as part A or part B. Therefore, if you purchased an advantage plan, you are looking at being covered for at least up to 80% of the allowable rate for DME. Some plans may even offer more.
It is essential to understand that regardless of what type of coverage you currently have, durable medical equipment will only be paid for if it is ordered by a physician who is enrolled in Medicare. You also need to ensure that the DME supplier is enrolled and participating as well.
There are very strict guidelines governing physicians and suppliers who are enrolled with Medicare and they must abide in order to stay enrolled. If your doctor or DME supplier is not participating, Medicare will not pay for any claims from them.
Knowing this information, it is very important that you check with your medical supplier before purchasing your DME equipment. They must be participating and accept assignment of Medicare fee schedules.
If a supplier is participating, but does not accept assignment, they can charge you for the full out of pocket price for the equipment. By doing your homework and knowing the right questions to ask both your DME supplier and physician, you can save yourself a lot of time, money and hassle in regards to Medicare coverage of durable equipment.
Medicare Coverage of Durable Equipment | Whats Covered
Medicare Coverage of Durable Equipment does not cover all durable medical equipment. They have strict guidelines regarding what is medically necessary and what is actually considered medical equipment. Below are some common examples of DME that is covered:
DME covered by Medicare (but not limited to):
- Blood sugar monitors
- Canes, walkers, crutches, wheelchairs (including power chairs)
- Commode chairs
- Hospital beds
- Infusion pumps and their supplies
- Oxygen equipment
- Suction pumps
- Traction equipment
DME that is NOT covered by Medicare (not limited to):
- Walk in bathtubs
- Humidifiers and dehumidifiers
- E-stim for wounds
- Exercise equipment
- Grab bars
- Spare oxygen tanks
- Raised toilet seats
- Stair lifts
**Medicare must consider the DME to be medically necessary for daily functioning, it cannot be a convenience or precautionary measure.
Renting vs. Buying DME
The decision to rent or to buy DME is usually not made by the patient, this is up to Medicare to decide. Since Medicare’s standards for DME dictate that it is a reusable item, they will require rental and reusal of most DME.
If you require a custom made piece of DME, it must pass Medicare’s guidelines before it will be approved and paid for when rental is not an option.
Renting medical equipment usually works to the advantage of the participant because, if the equipment is faulty or breaks, they are not usually responsible to pay for the repairs out of their own pockets.
Your Medicare approved supplier will be able to tell you if the piece of equipment that was ordered for you is available to rent or will need to be purchased.
What is Upgraded Equipment?
When a piece of medical equipment is approved by Medicare, they typically approve the most basic model of that equipment. For example, if your physician prescribed a walker to you for getting around safely, Medicare will likely approve the most basic walker model.
If you desire a walker that has a hand brake and wheels, this would be considered upgraded equipment and may not be covered.
There are some cases, though, were upgraded equipment will be considered but it needs to be explicitly stated on your prescription why those upgrades are medically necessary. For the walker example, if the patient does not have the physical strength to lift the walker, one with upgraded wheels is medically necessary and will likely be approved.
Upgrades that are not necessarily medically necessary, but are desired by the patient, are still possible with the use of an ABN (advanced beneficiary notice).
This is a document given to the patient by the supplier which requires the patient’s signature and states that the patient is responsible for the additional costs. The supplier will then send the ABN to Medicare when they request for reimbursement for the equipment.
Durable medical equipment coverage is a great benefit offered to you by Medicare. However, it is important that you understand Medicare’s policies and restrictions regarding coverage before making any decisions.