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Ashford Insurance

Does Medicare cover Durable Medical Equipment?

Sarah Fuhrmann

Sarah Fuhrmann

Sarah Fuhrmann is an agent of Ashford Insurance an independent health insurance agency specializing in Texas Medicare insurance.

Many seniors assume Medicare automatically pays for mobility equipment like canes, walkers, and wheelchairs; oxygen equipment like nebulizers and CPAPs; other devices like continuous glucose monitors, respirators, infusion pumps and hospital beds.

This assumption is only partially true. Medicare Part B does cover what’s called “durable medical equipment” or DME for short.

In order for DME to be covered by Medicare, it must meet certain criteria. Assuming the equipment is eligible, traditional Medicare usually covers 80 percent of the cost after the patient meets the annual Part B deductible. The patient is then responsible for the remaining 20 percent. Of course, some Medicare supplement and Medicare Advantage plans may cover the 20 percent depending on the plan.

Medicare’s definition of DME is:

  • It is durable. This means that it must be something that you will use over and over again for an extended period of time. Items that are disposable after one use or are only needed for a short period are not eligible. Generally, Medicare expects “durable” items to have a useful life of at least three years.
  • It must be necessary and reasonable for the treatment of a condition or injury. The item must be primarily and customarily needed for a medical purpose (generally the DME is not useful to someone who is not sick or injured).
  • Appropriate for use in the “home.” “Home” does not include a hospital or skill nursing facility.

To qualify for DME coverage you must meet the following criteria:

  • The beneficiary must be enrolled in Medicare Part B; and
  • Need for DME is documented by a practitioner who certified the medical necessity; and
  • The practitioner completes an order (maybe with the assistance of a physical therapist or occupational therapist; and
  • After a face-to-face meeting with the treating practitioner (certifications via telehealth are permitted).

GUIDELINES

To obtain DME, ask your physician to recommend a supplier they know and have worked with before. You can at: (enter your zip code, then locate the covered item or service on the list.) Review the list of suppliers that accept Medicare assignment for that item or service. If no suppliers accept assignment, look for enrolled suppliers. Contact several suppliers for information.

SPECIFIC ITEM

Provider prescribes the specific item.

The provider must document the need for that specific item/supply in the medical record.

The DME supplier is required to do one of the following:

Give the exact brand/form of item/supply requested, or

Work with the provider to find another brand/form the provider agrees is both safe and effective.

Under Traditional Medicare, the beneficiary costs for Medicare-covered DME are as follows:

Annual Part B deductible, if not already met; and

20 percent of the Medicare-approved amount for Medicare-covered items, if the Medicare-enrolled supplier “participates” in Medicare (accepts Medicare “assignment” as the full price.

If a Medicare-enrolled supplier does not participate in Medicare there is no limit on the amount they can charge. Remember Medicare will only pay up to the Medicare-approved/allowed amount.

If a supplier is not enrolled in Medicare, no payment will be made by Medicare.

Typically, delivery, set-up, and training are usually included as part of Medicare’s payment for DME when an item is obtained from a Medicare-participating supplier.

NON-COVERED DME

Equipment designed for comfort/convenience

Physical fitness or self-help equipment

Devices and equipment used for environmental control

Advantage Plans  and DME

Medicare Advantage plans must cover at least the same items and services as Traditional Medicare; The plans may cover more, but not less.

A beneficiary’s out-of-pocket DME costs will depend on the Medicare Advantage plan chosen, typically 20% — 50% coinsurance.

To determine if an item is covered, and the cost for a beneficiary, it’s best to call the plan and ask for the “Utilization Management Department”.

If you are denied DME coverage, you can always appeal. Begin the appeal process through the Advantage plan. Follow the directions in the plan’s initial denial notice and plan materials.

RESOURCES

Locate suppliers at:

“Your Guide to Medicare’s Durable Medical Equipment Prosthetics, Orthotics & Supplies (DMEPOS) Competitive Bidding Program”

“Medicare Coverage of Durable Medical Equipment and Other Devices”

“Medicare’s Wheelchair & Scooter Benefit”

Photo by Hans Moerman on Unsplash

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Sarah Fuhrmann

Sarah Fuhrmann

Sarah Fuhrmann has been helping Medicare eligibles in Texas with their Medicare Insurance since 2018.