Orlando Harmon
Whether your health insurance covers durable medical equipment (DME) depends on your insurance provider and plan. DME is typically defined as reusable medical equipment that is medically necessary and has a lifetime of at least three years. Medicare Part B covers DME if it is deemed medically necessary by a doctor and meets coverage requirements. Medicaid also offers DME coverage. Private health insurance plans are not required to cover DME, but many do. If your insurance covers DME, you will typically need a prescription from your doctor and may have to rent or buy the equipment.
| Characteristics | Values |
|---|---|
| What is covered | Medical equipment that is durable, medically necessary, and able to withstand repeated use. |
| What is not covered | Vehicles, car customizations, home improvements like ramps and grab bars, equipment intended for use outside the home, and equipment that is not suitable for at-home use or provides comfort or convenience. |
| Who provides coverage | Medicare Part B, Medicaid, and some private health insurance plans. |
| How to get coverage | Speak with your doctor or healthcare provider to determine if the equipment is medically necessary, then with your plan provider to see if you qualify for coverage. You may need prior authorization from a provider if the equipment costs over a certain amount. |
| Cost | Depending on your plan, you may be responsible for a percentage of the costs, such as through coinsurance. |
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What You'll Learn
Medicare Part B coverage
Part B of Medicare covers a wide range of medical services and supplies that are considered "medically necessary" to treat or manage a health condition. This includes doctor's services, such as office visits, consultations, and evaluations, as well as outpatient care received in a hospital or other healthcare facility. Laboratory tests, X-rays, and other diagnostic procedures ordered by a doctor are also covered under this part.
In terms of durable medical equipment (DME), Medicare Part B provides coverage for certain items that are deemed necessary for use in the home. This includes things like wheelchairs, walkers, crutches, and canes, as well as hospital beds and oxygen equipment. Prosthetic devices, orthotics, and other necessary DME may also be covered. To qualify for coverage, the equipment must be ordered by a doctor who is enrolled in Medicare and accepts assignment of the Medicare-approved amount as payment in full.
Additionally, Medicare Part B covers some preventive services, such as screenings and vaccinations, which can help identify potential health issues early on. Examples include flu shots, pneumonia vaccines, colorectal cancer screenings, and mammograms. Coverage for certain counselling services, like smoking cessation and obesity counselling, is also included in Part B. It's important to note that while Part B covers a wide range of services, specific limitations or conditions may apply, and some items or services may require prior authorization.
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Medicaid coverage
Medicaid and Medicare both offer coverage for durable medical equipment (DME). However, it is important to note that not all DME may be covered, and the specific items covered by Medicaid can vary by state.
DME is defined as reusable medical equipment deemed medically necessary by a doctor or healthcare provider. Examples include wheelchairs, walkers, hospital beds, home oxygen equipment, diabetes self-testing equipment, and certain nebulizers. It is important to note that DME is intended for home use, so vehicles and car customizations are typically not covered. Similarly, equipment that is intended for use outside the home or not suitable for home use, such as paraffin bath units used in hospitals, is generally not covered.
To be eligible for Medicaid coverage, DME typically requires prior authorization from a provider if the equipment costs exceed a certain amount. You will need a written prescription from your primary care physician or another medical professional. You will then need to find an approved DME supplier, which you can usually search for on your insurance company's website. Depending on your plan, you may have the option to rent or buy the DME, and your insurance company may specify a preferred brand.
It is important to review your specific Medicaid plan to understand the coverage details for DME. Some plans may cover the full cost of in-network DME, while others may require you to pay a percentage of the costs through coinsurance. Additionally, keep in mind that Medicaid and Medicare have different coverage policies, so having both options available can provide alternative coverage options for certain items.
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Private health insurance plans
DME is intended for home use, so vehicles, car customizations, and home improvements like ramps and grab bars are excluded. However, if the insurance company decides that these improvements are medically necessary, they may be covered as DME or through another part of your health insurance.
Your insurance company might give you the option to rent or buy DME, depending on the device. For example, an arm sling or neck brace might have to be purchased, but you might be able to rent a hospital bed. Some health plans might not charge you and cover the cost of in-network DME, while others might make you responsible for coinsurance or a percentage of the costs, whether rented or purchased.
To find out how much your item will cost, talk to your doctor or healthcare provider. Your insurance company will determine what is considered DME and outline what you need to do to get it. Typically, DME eligibility requires prior authorization from a provider if the equipment costs over a certain amount. You will need a written notice or prescription from your primary care physician or another medical professional, and you will need to find an approved DME supplier. Your insurance company website usually has a searchable database or list of approved suppliers. Depending on your plan structure, you might see both in- and out-of-network DME suppliers, which might be priced differently. Your health insurance company might also request that you get your DME from a preferred brand.
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Eligibility requirements
Medicare
Medicare Part B covers medically necessary DME if prescribed by a Medicare-enrolled doctor or healthcare provider for use in your home. This includes equipment such as walkers, hospital beds, home oxygen equipment, diabetes self-testing equipment, and certain nebulizers. Medicare generally pays for only one piece of DME for a particular health condition at a time and usually covers the most basic form of the equipment needed. It's important to note that Medicare does not cover equipment that modifies your home, such as ramps or widened doors, or equipment intended for use outside the home.
Medicaid
Medicaid also offers DME coverage, which may include some items not covered by Medicare. The specific coverage will depend on the state and the individual's circumstances. For example, in Texas, Medicaid covers customized power wheelchairs in nursing facilities and allows for certain incurred medical expense (IME) deductions for other DME.
Private Health Insurance
Private health insurance plans are not required to cover DME, but many do. Coverage and eligibility requirements vary among plans, so it's essential to check with your specific plan provider. Typically, prior authorization from a healthcare provider is required if the medical equipment costs exceed a certain amount. The insurance company determines what is considered DME and outlines the process for obtaining coverage.
Veterans Affairs (VA)
The VA has specific forms and processes for requesting DME for veterans, including routine and urgent requests. Routine DME requests should be made within 24 hours or the next business day after completing the healthcare services that generated the prescription. Urgent or emergency DME requests, needed to stabilize or decrease the risk of further injury, are covered under the authorization for the visit.
It's important to note that each insurance provider has its own specific eligibility requirements and coverage policies for DME. Always consult your insurance plan or provider to understand the exact eligibility requirements and coverage details for your specific situation.
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Renting or buying
Whether you rent or buy durable medical equipment (DME) depends on your health insurance plan, the type of equipment, and your personal circumstances.
Medicare Part B (Medical Insurance) covers medically necessary DME if prescribed by a Medicare-enrolled doctor for use at home. You may need to rent or buy the equipment, or you may have the option to choose. For example, you might have to buy an arm sling or neck brace, but you could rent a hospital bed. Medicare typically covers 80% of the cost of a monthly rental fee for 13 months, after which the equipment becomes your property.
Some health insurance plans may not charge you for in-network DME, while others may require coinsurance, where you pay a percentage of the costs. If you are paying out of pocket, renting may be a less expensive option than buying, as you may not be able to recoup the purchase price through resale. Rental agreements usually cover maintenance and repair costs, whereas buyers are responsible for these.
When deciding whether to rent or buy DME, consider how long you will need the equipment, how often you will need to repair or replace it, and whether you will need to travel with it. If you have a fixed income, renting may be a more manageable option due to the lower monthly payments.
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Frequently asked questions
DME is typically used in the home for a medical reason and is durable, meaning it includes devices that have a lifetime of at least 3 years and can withstand repeated use.
Medicare Part B covers medically necessary DME if prescribed by a Medicare-enrolled doctor or healthcare provider.
Some examples of DME covered by Medicare include prosthetics, orthotics, wheelchairs, walkers, hospital beds, home oxygen equipment, diabetes self-testing equipment, and certain nebulizers.
Private health insurance plans are not required to cover DME, but many do. It's important to check with your plan provider to understand your specific coverage.
First, speak with your doctor or healthcare provider to determine if DME is medically necessary for you. If so, you will need a prescription or order from your doctor to access coverage. Then, you can obtain DME from Medicare-approved suppliers that take assignment.
