Alyssa Lane
Durable medical equipment (DME) is long-lasting and versatile equipment that improves a patient's quality of life. DME includes wheelchairs, walkers, hospital beds, glucose monitors, and oxygen equipment, which can be covered by insurance. Medicare Part B covers medically necessary DME, while Medicare Advantage plans may require prior authorization. Private insurance plans may also cover DME, but specifics vary. Understanding your insurance plan's coverage for DME is essential, as some plans have specific requirements and limitations.
| Characteristics | Values |
|---|---|
| Definition | Equipment that can withstand heavy use to help complete daily activities |
| Examples | Wheelchairs, walkers, scooters, hospital beds, glucose monitors, pumps, canes, oxygen equipment, diabetes self-testing equipment, prosthetics, orthotics, etc. |
| Insurance Coverage | Covered by Medicare Part B if deemed medically necessary and with a prescription from a doctor |
| Covered by Original Medicare and Medicare Advantage with a prescription | |
| Private insurance coverage varies but most cover wheelchairs and mobility devices | |
| Medicare Advantage may require prior authorization and use of a doctor and supplier within the plan's network |
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What You'll Learn
Medicare Part B coverage
Medicare Part B covers durable medical equipment (DME) that meets specific criteria, such as being durable, medically necessary, and appropriate for home use. DME is defined as equipment that is durable and reusable, expected to last at least three years, and used when you are sick or injured. Examples of DME covered by Medicare Part B include wheelchairs, hospital beds, pumps, canes, walkers, oxygen tanks, and prosthetic devices that replace all or part of an internal bodily organ.
Medicare Part B also covers certain prescription medications and supplies used with DME, even if they are disposable or single-use items. For example, medications used with nebulizers and lancets and test strips for diabetes self-testing equipment are covered. It's important to note that Medicare does not cover all types of equipment and supplies, and there may be specific exclusions.
To qualify for Medicare Part B coverage for DME, the equipment must be prescribed by your primary care provider (PCP). Additionally, it is recommended to ensure that your doctors and DME suppliers are enrolled in Medicare. Before obtaining DME, ask the supplier if they participate in Medicare. Participating suppliers must accept assignment, which means they can only charge you the coinsurance and Part B deductible for the Medicare-approved amount.
Once you meet the Part B deductible, you typically pay 20% of the Medicare-approved amount when your supplier accepts assignment. However, if suppliers do not participate in Medicare and do not accept assignment, you may be responsible for the full cost of the DME. It is worth noting that prior authorization (PA) can help ensure that a treatment or piece of equipment is medically necessary and keep your costs down. Your doctor can submit a PA request on your behalf, which usually takes up to two weeks for processing.
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Private insurance coverage
Generally, private insurance plans that do cover DME may limit what equipment is covered and set certain conditions for coverage. For example, some plans may require prior authorization from a provider for equipment that costs over a certain amount. Additionally, your insurance company may require you to obtain your DME from an approved supplier, which could be either in-network or out-of-network and may be priced differently.
Some common types of DME that are often covered by private insurance plans include wheelchairs, mobility devices, prosthetics, orthotics, and diabetes self-testing equipment. It is worth noting that some plans may offer the option to rent or buy certain DME, and the cost structure can vary depending on whether the equipment is rented or purchased.
It is always advisable to consult your insurance provider directly to understand the specific coverage offered by your private insurance plan and to ensure that you are following the necessary steps to obtain coverage for your required DME.
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Prior authorization
In the context of DME, prior authorization helps suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS) ensure that applicable Medicare coverage, payment, and coding rules are met before items are delivered. The prior authorization program helps to protect the Medicare Trust Fund from improper payments while ensuring that beneficiaries receive the DMEPOS items they need in a timely manner.
The Centers for Medicare & Medicaid Services (CMS) maintains a Master List of DMEPOS items that may be subject to prior authorization. This list is updated at least once per year and is intended to streamline regulatory requirements, simplify DMEPOS payment requirements, and reduce provider and supplier burden. Items on the list include power wheelchairs, power mobility devices, and pressure-reducing support surfaces.
To initiate the prior authorization process, a doctor will submit a PA request. This process can take up to two weeks, and patients can check the status of their request by logging into their secure member website or contacting Member Services.
It is important to note that prior authorization requirements may be suspended by CMS under certain circumstances, such as in cases where DME is urgently needed to stabilize or reduce the risk of further injury.
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Medicare Advantage coverage
Durable medical equipment (DME) is defined as equipment that is durable, medically necessary, and appropriate for home use, long-term care, or getting around. Medicare Part B covers DME that meets these criteria. Medicare Advantage Plans also cover DME, and the types of equipment covered are the same as those covered by Original Medicare.
To qualify for Medicare coverage, DME must be prescribed by your primary care provider (PCP). Examples of DME include wheelchairs, hospital beds, pumps, canes, walkers, oxygen tanks, and prosthetic devices. Diabetic supplies like test strips and lancets may also be covered as DME with a prescription from your doctor.
Medicare covers different kinds of DME in different ways. For some equipment, you may need to rent or buy it, while for others, you may be able to choose whether to rent or buy. It is important to ask a supplier if they participate in Medicare before acquiring DME. If suppliers are participating in Medicare, they must accept assignment, which means they can only charge you the coinsurance and Part B deductible for the Medicare-approved amount. If suppliers are not participating and do not accept assignment, you may have to pay the full cost of the DME.
Prior authorization (PA) is a preapproval process that helps keep costs down and ensures that a treatment or medicine is medically necessary. Your doctor will submit a PA request on your behalf, which can take up to two weeks.
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Diabetic supplies
In the United States, the cost of diabetes supplies can be covered by Medicare, which considers most diabetic supplies as durable medical equipment (DME). Medicare Part B covers diabetes supplies like test strips, insulin pumps, and continuous glucose monitors, including sensors, transmitters, and receivers. Medicare Part D covers diabetes medication and supplies like syringes and insulin. If you are dual-eligible for Medicare and Medicaid, you can get expanded coverage for your diabetes supplies. Medicare will cover 80% of the bill, and Medicaid can pay for some or most of the remaining costs of medications and supplies.
Medicare Advantage (Part C) plans are required to cover everything that Original Medicare covers. However, there may be specific rules and requirements for getting coverage, such as prior authorization or using a doctor and a supplier within the plan's network.
Medigap, or Medicare supplement insurance, may also help with costs. It covers a variety of diabetes-related services and supplies under specific conditions, such as pumped insulin and the insulin pump when medically required.
It is important to note that Medicare does not cover disposable medical supplies that are used once and then thrown away. However, some disposable supplies, like test strips for diabetes, may be covered under Medicare Part D. Additionally, if you qualify for Medicare home health, Medicare may cover certain other disposable supplies, such as intravenous supplies, gauze, or catheters.
To receive coverage for diabetic supplies, you will need a prescription from your doctor, and you must obtain your supplies from Medicare-enrolled suppliers.
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Frequently asked questions
DME is defined as equipment that is durable and reusable, with a lifetime of at least 3 years. Examples include wheelchairs, hospital beds, pumps, and canes.
Yes, Medicare covers DME when it is medically necessary and prescribed by a doctor. Medicare Part B covers 80% of the cost of DME, and the patient is responsible for the remaining 20%.
Examples of DME covered by Medicare include wheelchairs, walkers, hospital beds, oxygen equipment, diabetes testing equipment, and prosthetics.
