Are you a Medicare beneficiary who needs medical equipment that provides therapeutic benefits for certain chronic medical conditions? If so, it’s good to know what durable medical equipment (DME) is and how it is covered under your health insurance plan. Medical devices are considered DME when they are primarily used for medical purpose, can stand repeated use, and benefits the patient’s ability to heal and/or remain active in his or her home. Parts of Medicare will cover various types of DME, but only your doctor can order or prescribe it for you to receive through the appropriate medical equipment supplier that meets the correct standards.
What Medicare will cover
In general, Medicare coverage of DME includes:
- Medicare Part A covers DME for beneficiaries who are in a skilled nursing facility or in a hospital as an inpatient.
- Medicare Part B covers medically necessary DME, which includes prosthetics, orthotics, power mobility devices and other supplies such as home oxygen equipment and hospital beds.
- Various prescription drugs or supplies (such as medications used with nebulizers or test strips for diabetes) are considered DME and are covered under Medicare.
Eligibility for Medicare beneficiaries can change for a number of reasons. This includes death, end of Medicare Part B, transfer to a Medicare Advantage plan or being admitted to a long-term care facility.
Durable medical equipment under Medicare Part B
In order for Medicare Part B to cover DME, criteria requires that the equipment be: durable, used for medical reasons, not useful to someone who isn’t sick or injured, used in your home, expected to last at least three years. The DME that Medicare covers is not limitted to, but includes:
- Air-fluidized beds and other support surfaces (these supplies are only rented)
- Blood sugar monitors
- Blood sugar test strips
- Commode chairs
- Continuous passive motion (CPM) machine
- Hospital beds
- Infusion pumps and supplies
- Manual wheelchairs and power mobility devices
- Nebulizers and nebulizer medications
- Oxygen equipment and accessories
- Patient lifts
- Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
- Suction pumps
- Traction equipment
Costs for durable medical equipment
The Medicare Part B deductible applies when purchasing or renting DME. Make sure your DME supplier and doctor are enrolled in Medicare. Medicare will not pay for claims submitted if either the doctor or medical device supplier is not enrolled.
Also, make sure the supplier participates in Medicare. When a supplier is enrolled in Medicare but is not participating, then it can charge any price. If the supplier is enrolled in and participating in Medicare, it must accept the assignment from your doctor. You then pay 20% of the Medicare-approved amount. In addition to asking your doctor how much he or she may charge for the DME, you can get a gauge costs by inquiring about such information as other insurance you use, the type of facility for the DME, and the location where you get it.
Make sure to ask the supplier questions as well, especially if you are unsure if you will be buying or renting the DME. Medicare pays for most DME on a rental basis or buys routine and inexpensive items such as canes and scooters. If you bought and own DME that is covered, then Medicare may pay for repairs and replacement parts. Should you rent the equipment, Medicare will help funding with monthly payments. How long those payments last depend on the type of equipment and its necessity. The supplier is responsible for picking up the equipment when you are done using it and if it needs repairs. You can find a supplier that’s enrolled in Medicare at this supplier directory or you can call 1-800-MEDICARE.
Durable medical equipment under Medicare Advantage
If you have a Medicare Advantage plan, it must cover the same DME as Original Medicare. Costs may vary depending on which supplemental plan you have. Call your plan and ask for “Utilization Management” to learn how much of the costs will be on your shoulders. Be sure to inquire about specific rules under Medicare Advantage as well. The plan may require approval for you to receive DME, and it may have a preferred list of DME suppliers.
The renting vs buying debate to save money
While the Affordable Care Act (ACA) saved roughly $86 million from 2011 to 2014 by eliminating lump-sum purchases on standard powered wheelchairs, it’s estimated that Medicare could’ve saved an additional $10 million if beneficiaries had been required to rent them on a monthly basis instead. There are questions about whether or not beneficiaries who need power wheelchairs are able to get them in a timely manner when renting, and if they are able to get them serviced once they own them after a 13-month rental. During the 13-month rental time, 16,626 of the 85,761 from 2011 to 2014 power wheelchairs were purchased by beneficiaries whose needs and eligibility changed during the time period. The 13-month rental time period has saved Medicare money for the past few years, but will it continue to do so with the issues of beneficiaries eligibility changing and difficulty with timeliness of accessing the rental and servicing once the power wheelchair is paid off? We’ll keep an eye on it for you.
The new Medicare Plus Card saves you up to 75% on things not covered by Medicare
Medicare doesn’t cover everything. Luckily, those on Medicare can now start saving on out of pocket expenses like prescription drugs, dental, vision, hearing, and more. Over 1 million people have already received their free Medicare Plus Card.