When you have surgery, an injury, or a medical diagnosis, you often need medical equipment to support your recovery and help you live your best life. Like most things, medical equipment is expensive.
If you have Medicare coverage, you might be asking “Does Medicare pay for durable medical equipment?” Fortunately, if your equipment is medically necessary and provided by a store that accepts Medicare assignments, it generally is covered.
Let’s take a look at common questions about durable medical equipment and how it’s covered by Medicare.
Durable medical equipment (DME) is the technical term for the equipment that can be used multiple times and is provided for a medical reason. These items are intended to help you complete your daily activities, and are medically necessary due to a medical condition or recent procedure.
What falls under durable medical equipment? Examples include crutches, walkers, wheelchairs, CPAP machines, bathroom aids, orthopedic braces, and respiratory care items like oxygen.
There are specific stores that specialize in providing DME to patients that need them. These providers will be approved by certain insurance programs, while other insurance plans won’t provide coverage there.
Making sure that you get your DME from a provider that accepts your insurance plan is essential if you want coverage. That means they either need to accept assignments from Medicare or be a part of your Medicare Advantage network.
Durable medical equipment that is prescribed by your doctor is generally covered by Medicare. Keep in mind that Medicare may cover the basic form of equipment rather than an advanced version with extra features. For example, for diabetes, Medicare (Part B) covers insulin pumps as DME
This guide isn’t long enough to include an exhaustive list of all the DME covered by Medicare, because a lot of items are available. If you’re wondering, “How do I get a rollator through Medicare,” keep in mind that equipment will only be covered if your doctor deems it medically necessary and you need it inside your home. If you want a power wheelchair but only need it for trips away from home, it will not be covered by Medicare.
What about other types of equipment? For example, does Medicare pay for a treadmill? Unfortunately, a treadmill is not considered a medical device. Equipment needed just for exercise or improved health is not covered by Medicare. It would be challenging to make a case that you medically need a treadmill, and to find a durable medical equipment provider who sells one.
The criteria for getting DME coverage is simple, which is why so many types of equipment are covered. The equipment must be:
If the equipment meets these criteria and you have Original Medicare, the medical equipment will be covered under Medicare Part B. That means you’ll pay your deductible (if it hasn’t already been covered), along with 20% of the Medicare-approved cost of the item. Medicare covers the other 80%.
Under some circumstances, Medicare may only cover the cost of renting the equipment instead of buying it. If you wanted to buy the equipment instead, you’d have to cover the cost.
Medicare Advantage plans must provide at least as much coverage as Original Medicare, and may have additional benefits as well. In particular, you may have a lower deductible or a lower copayment when you need DME. Be sure to contact your insurance provider to get the details of your plan. Remember, you’ll need to use a DME provider that’s in your insurance network.
If you know that you need medical equipment, how do you go about getting it?
The first step is to see your doctor and have them prescribe the equipment. Once you have the prescription, you can take it to a DME provider that’s enrolled in Medicare and accepts assignments. They will let you know how soon you will receive the equipment, and the store will also bill Medicare for you. You’ll receive a bill in the mail for your portion of the equipment cost.
If you have Medicare Advantage, the process is similar. You’ll get a prescription and take it to a DME provider that’s in the insurance network. They will let you know how soon the equipment will be available and bill the insurance company. You’ll receive a bill for your out-of-pocket costs.
How often can you get DME from Medicare? Each type of equipment will have a timeframe that you use it before you can upgrade or replace it. For example, a CPAP mask might be covered every three months, but a new walker is only covered every five years. You’ll want to talk to your insurance provider and DME store to find out how often you can get new equipment.
This guide answered most of the questions we commonly receive about Medicare coverage of durable medical equipment. However, you might have questions about your specific situation or be interested in comparing Medicare plans based on your needs. We’re here to help. Contact us today for more information about Medicare and DME.
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