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Medicare Durable Medical Equipment Benefit

The Medicare Durable Medical Equipment Benefit: Everything You Need to Know

Your Medicare Part B benefits cover durable medical equipment (DME) deemed medically necessary by your doctor. However, to take advantage of the benefit, you must meet Medicare’s requirements. In this post, we share everything you need to know about the Medicare durable medical equipment benefit.

What Is Durable Medical Equipment?

The first thing to understand is how Medicare defines durable medical equipment. Please note that, while many of these items are available over the counter, Medicare only covers them when they’re prescribed by your doctor.

Additionally, your DME must be durable, meaning it holds up to repeated use over a period of several years. There must also be a medical reason for the item, making it generally useless for someone who is healthy. Finally, the DME must be prescribed for use in your home, not a healthcare facility.

Examples of Durable Medical Equipment

Durable medical equipment covered under Medicare Part B includes:

  • Diabetes care items, such as blood sugar monitors, lancets, and test strips
  • Mobility devices, such as wheelchairs, canes, and walkers
  • Commode chairs
  • Hospital beds
  • Oxygen equipment

For the full list of covered items, please see Medicare’s DME page.

Diabetes testing equipment covered by Medicare

How Much Does Medicare Pay for Durable Medical Equipment?

Medicare covers 80 percent of the cost for DME, assuming you use a participating supplier. You are responsible for the remaining 20 percent, unless you have a Medigap plan. Most Medicare Supplement plans cover 100 percent of your Part B co-insurance costs. There are two exceptions. Plan K covers 50 percent and Plan L covers 75 percent.

Options for obtaining DME typically include renting or buying the equipment. Medicare coverage varies depending on the item and your diagnosis.

What Are the Medicare Requirements for Using the DME Benefit?

Medicare provides the following guidelines to any beneficiary looking to use the durable medical equipment benefit.

First, you must have Medicare Part B. If you only enrolled in Part A, Medicare will not cover the cost of your durable medical equipment.

The doctor who prescribed your DME must accept assignment. This is rarely an issue, since most doctors notify you immediately if they do not accept Medicare. If you aren’t sure, though, enter your provider’s information in the Medicare Physician Compare tool. Just enter your location information, the name of your provider, and hit Search. If the doctor’s name shows up, they accept assignment.

Your DME supplier must also participate in the Medicare program to ensure Medicare covers 80 percent of the cost. Ask the supplier specifically whether they accept Medicare. If they do not, Medicare will not pay any claims they submit for payment. That leaves you responsible for 100 percent of the cost.

Search the Medicare Supplier Directory for a list of qualifying DME suppliers in your area.

The equipment prescribed must be considered “reasonable” and “necessary.” For example, if you have diabetes, blood sugar testing equipment would be considered reasonable and necessary. If you have mobility issues that interfere with the activities of daily living, your doctor may prescribe a walker, cane, or wheelchair.

Finally, to qualify for the DME benefit, you must be at home. That means Medicare won’t cover the equipment if you are currently in a hospital, skilled nursing facility, or hospice. That’s because your Part A insurance should cover any equipment deemed medically necessary when you’re in one of those facilities. Upon discharge, though, your doctor may prescribe durable medical equipment. That’s when your Part B insurance kicks in.

Additional Requirements for DME

Medicare may have additional requirements, depending on the type of durable medical equipment. The most common example of this is the hierarchy Medicare employs for mobility items. Essentially, this boils down to the minimum level of assistance required for you to get around your home safely.

Durable Medical Equipment coverage hierarchy

The hierarchy looks like this:

  • Canes
  • Walkers
  • Manual wheelchairs
  • Power wheelchairs and scooters

So, if you can safely use a cane to resolve your mobility issues, Medicare will not pay for a walker or wheelchair. If not, the next step is a walker.

If you cannot use a walker or a cane safely, you may qualify for a wheelchair (always assuming it’s prescribed by your doctor). For all equipment – mobility and otherwise – it must be for use in the home. You can use it outside the home, of course, but it must be for use in the home. In other words, Medicare will not cover a cane for use in the home and a wheelchair for outside the home.

Understanding Your Medicare Options

Would you like to reduce your out-of-pocket costs for your durable medical equipment? Consider a Medicare Supplement Insurance plan. If you need help understanding your Medicare options, the licensed agents at Medicare Solutions can help. Just call us toll-free at 855-350-8101. You can also use our online plan finder tool to see Medicare plans in your area.

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