What is Durable Medical Equipment (DME)?
Before exploring coverage details, it's crucial to understand what Medicare classifies as Durable Medical Equipment, or DME. To be considered DME, the equipment must meet four key criteria:
- Durable: The item must be able to withstand repeated use.
- Medical Purpose: It must be used for a medical reason and not just for convenience.
- Home Use: The equipment must be appropriate for use in your home, although it can also be used outside the home.
- Expected Lifespan: It must be likely to last for at least three years.
Items like canes, hospital beds, oxygen equipment, and wheelchairs generally fall under this category. Disposable supplies, however, are typically not covered under the DME benefit, though there are some exceptions for supplies used with covered equipment.
Medicare Part B: The Home for DME Coverage
For most seniors, Medicare Part B is the part of Original Medicare that covers medically necessary DME. After you have met your annual Part B deductible, Medicare will generally pay 80% of the Medicare-approved amount for the equipment. You are then responsible for the remaining 20% coinsurance.
For a specific piece of equipment to be covered, you must meet certain requirements:
- A Medicare-enrolled doctor must prescribe the equipment for a medical condition.
- You must obtain the equipment from a Medicare-approved supplier.
- The equipment must be for use in your home.
Renting vs. Buying Medical Equipment
Medicare's coverage depends on the type of DME and its classification. Some items must be rented, while others can be purchased, and for some, you have the option to choose.
- Capped Rental Items: For certain expensive items like hospital beds and oxygen equipment, Medicare requires you to rent the equipment for a set period (often 13 months). After this time, you own the equipment.
- Routinely Purchased Items: Inexpensive or routinely purchased items, such as canes and walkers, can often be purchased outright.
- Frequently Serviced Items: Some equipment, like ventilators, is paid on a monthly rental basis as long as it is medically necessary, due to the need for frequent servicing.
Examples of Equipment Covered and Not Covered
Medical Equipment Covered by Medicare
Medicare Part B covers a wide range of DME, including:
- Wheelchairs and power-operated vehicles (scooters)
- Walkers, canes, and crutches
- Hospital beds
- Oxygen equipment and accessories
- Continuous Positive Airway Pressure (CPAP) machines
- Patient lifts
- Infusion pumps and supplies
- Pressure-reducing mattresses and beds
- Commode chairs
- Blood sugar monitors and test strips
What Isn't Covered?
Medicare does not cover every item that could be considered helpful. Generally, excluded items include:
- Equipment for convenience, such as grab bars or bath seats.
- Home modifications, such as permanent ramps or stair lifts.
- Items for use exclusively outside the home.
- Most disposable medical supplies, with some exceptions for items used with covered equipment.
Original Medicare vs. Medicare Advantage (Part C)
Understanding the difference in coverage between Original Medicare and a Medicare Advantage Plan is essential for navigating your options.
| Feature | Original Medicare (Parts A & B) | Medicare Advantage (Part C) |
|---|---|---|
| Coverage | Covers medically necessary DME under Part B. | Must cover at least the same DME as Original Medicare, but may offer more. |
| Network | Can use any Medicare-approved supplier in the country. | May require you to use an in-network doctor and supplier for coverage. |
| Costs | Pay 20% coinsurance after Part B deductible is met. | Plan sets its own cost-sharing, which could be a set copay or different coinsurance. |
| Referrals | No referrals needed for DME. | Might require prior authorization or a referral from your primary care provider. |
How to Get Your Equipment Covered
Follow these steps to ensure your medical equipment is covered by Medicare:
- See a Doctor: Schedule a face-to-face appointment with your physician. They will assess your condition and determine if the equipment is medically necessary.
- Get a Prescription: Your doctor will provide a written order or prescription for the specific type of equipment you need. This order is a crucial part of your medical record.
- Find a Supplier: Use Medicare's website to find a supplier who is enrolled in the program and accepts assignment. Accepting assignment means they agree to the Medicare-approved payment amount.
- Check Prior Authorization: Your supplier may need to submit a request for prior authorization, especially for more expensive items like power wheelchairs. They will handle this process with Medicare.
- Understand Your Costs: Work with your supplier to confirm what your portion of the costs will be, including any coinsurance or deductibles.
What if Your Claim is Denied?
If Medicare denies your claim for medical equipment, you have the right to appeal the decision. Start by reviewing your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) to understand why the claim was denied. You can then submit a formal appeal with additional documentation from your doctor if needed.
Conclusion
For seniors needing medical equipment, Medicare provides significant coverage through its Part B benefit. By ensuring your equipment is medically necessary, prescribed by a qualified doctor, and obtained from a Medicare-approved supplier, you can get the support you need. Whether you have Original Medicare or a Medicare Advantage plan, understanding the specific rules and processes is key to securing your benefits.
For more detailed information on DME coverage and specific items, consult the official website of the Centers for Medicare & Medicaid Services.
