What DME is not covered by Medicare ?
Working out what is and isn’t paid for by Medicare Parts A and B, and other plans you may have, is at first very confusing. So hopefully I can help you.
Medicare’s definition of Durable Medical Equipment is “Durable Medical Equipment is reusable medical equipment like, walkers, wheelchairs, or hospital beds”
What DME is not covered by Medicare ? Any DME which is
- not prescribed by a Medicare enrolled doctor, or treating practitioner (such as a nurse practitioner, physician assistant, or clinical nurse specialist)
- not bought from a Medicare-enrolled supplier
- intended for use outdoors and not required indoors i.e. if you do not need a scooter indoors you can not get one just for going out
- any medical equipment that cannot last 3 yrs of repeated use
- equipment which is not medically necessary
is not covered by Medicare.
Medicare’s basic criteria for DME’s
Durable medical equipment has to meet these basic criteria for it to be covered by Medicare:
- Durable (it must be able to withstand repeated use over a sustained period of time)
- Used for a medical reason, as opposed to for comfort
- Not usually useful to someone who isn’t sick or injured
- Used in your home
- Generally has an expected lifetime of at least 3 years
So if the equipment you are looking at doesn’t meet these criteria you probably won’t be able to get it covered by Medicare.
Most bathroom safety equipment is not considered medically necessary and, as such won’t be covered by Medicare.
Bathroom safety items such as grab bars, raised toilet seats, shower and bath chairs, bathtub lifts are considered to be comfort items and are not covered as DME’s by Medicare. But you may be able to get them covered by Medicaid, state waivers, HCBS programs, Veterans’ Benefits, state funded grants and more, if you qualify.
If you are interested in Medicare, Medicaid and other funding available for bathroom safety equipment, I have an extensive article here.
DME’s typically not covered by Medicare
Please note that this list only covers items covered by Medicare Parts A and B, otherwise known as Original Medicare.
If you or your loved one has a Medicare Advantage Plan (Medicare Part C), which is a supplemental private policy, it may cover other items and they have more benefits than with Original Medicare.
Legally Medicare Advantage Plans must cover, as a minimum, the same as Medicare Parts A and B, but they may also have dental, hearing and vision coverage as well.
Augmentative Communication Device
Bed Exit Alarms
Bed Sensor Pads
Beds – Lounge
Blood Glucose Analyzers
Braille Teaching Texts
Caregiver Paging Systems
Catheters – except those which are used for permanent medical conditions where the catheter is considered as a prosthetic
Chair Exit Alarms
Chair Sensor Pads
Contact Lenses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens
Disposable Bed Protectors
Door Exit Alarms
Electrical Wound Stimulation
Exit Alarm Mat
Eye Glasses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens.
Heat and Massage Foam Cushion Pad
Heating and Cooling Plants
Humidifiers – not room humidifiers
Injectors (hypodermic jet pressure powered devices for Insulin injection)
Motion Sensor Exit Systems with Pagers
Over bed Tables
Paraffin Bath Units (if not Portable)
Portable Room Heaters
Portable Whirlpool Pumps
Preset Portable Oxygen Units
Pull String Alarms
Raised Toilet Seats
Special TV Close Caption
Speech Teaching Machines
Surgical Face Masks
Telephone Alert Systems
Television Assistive Listening Devices
Walk in Bathtubs
DME’s typically covered by Medicare
As well as durable medical equipment you can get Medicare coverage for prosthetics and also corrective lenses for certain conditions. For convenience sake I have listed those items here as well.
Please note that if you have a Medicare Advantage Plan (Medicare Part C), this is private coverage, and you need to contact your insurer as they may have extra benefits not covered by Medicare Parts A and B.
Legally Medicare Advantage Plans have to cover everything Medicare Parts A and B cover, but for example they may also cover hearing, vision and dental as well.
Alternating Pressure Pads and Mattresses
Audible/visible Signal Pacemaker Monitor
Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
Bed Side Rails
Bed Trapeze – covered if your loved one is confined to their bed and needs one to change position
Blood sugar monitors
Blood sugar (glucose) test strips
Canes (however, white canes for the blind aren’t covered)
Continuous passive motion (CPM) machines
Continuous Positive Pressure Airway Devices, Accessories and Therapy
Cushion Lift Power Seat
Digital Electronic Pacemaker
Electric Hospital beds
Gel Flotation Pads and Mattresses
Glucose Control Solutions
Infusion pumps and supplies (when necessary to administer certain drugs)
Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
Mobile Geriatric Chair
Nebulizers and some nebulizer medications (if reasonable and necessary)
Oxygen equipment and accessories
Patient Lifts (a medical device used to lift you from a bed or wheelchair)
Postural Drainage Boards
Self-Contained Pacemaker Monitor
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
Urinals (autoclavable hospital type)
Whirlpool Bath Equipment – if your loved one is homebound and the pool is medically needed. If your loved one isn’t homebound Medicare will cover the cost of treatments in a hospital.
Prosthetic and Orthotic Items
Orthopedic shoes only when they’re a necessary part of a leg brace
Arm, leg, back, and neck braces (orthotics), as long as you go to a supplier that’s enrolled in Medicare
Artificial limbs and eyes
Breast prostheses (including a surgical bra) after a mastectomy
Ostomy bags and certain related supplies
Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.
Cataract glasses (for Aphakia or absence of the lens of the eye)
Conventional glasses or contact lenses after surgery with insertion of an intraocular lens
Important: Only standard frames are covered. Medicare will only pay for contact lenses or eyeglasses provided by a supplier enrolled in Medicare, no matter who submits the claim (you or your supplier).
If my DME’s are covered by Medicare do I have to pay anything myself?
It is very important to understand that Medicare Suppliers who are enrolled in the Medicare Program, do not have to accept the Medicare-approved price if they do not wish to.
In this case, Medicare will pay the Medicare-approved price for the equipment to the supplier for your equipment, but if the supplier’s price is higher you will end up paying the 20% co-payment of the Medicare-approved price, and the difference between the Medicare-approved price and the suppliers price, instead of just the 20% co-payment of the Medicare-approved price.
How can I get the best deal on Medicare covered DME’s
Medicare enrolled suppliers are divided into two camps –
- Medicare Suppliers
- Medicare “Participating” Suppliers
The Medicare Participating Suppliers have accepted what is known as “assignment”. This means that they have agreed to charge the Medicare-approved price only. When you buy your DME’s from a Medicare Participating Supplier you will not be paying more than the 20% co-payment of the Medicare-approved price for the equipment.
If your supplier is a not a “participating supplier this means that they have agreed to take payment from Medicare, but that they don’t have to accept “assignment” if they don’t want to.
To get DME’s at the lowest price through Medicare, you must make sure that your supplier is enrolled in Medicare and that they accept “assignment”, prior to doing anything else.
How much will I pay ?
If your supplier is a “participating” supplier, meaning he accepts assignment, you will generally pay 20% of the medicare-approved amount after you have paid your Medicare deductible for the year.
Prices may vary somewhat as Medicare rents as well as buys equipment from suppliers.
If you are on a Medicaire Advantage plan you will need to check with your plan.
Can I upgrade my DME’s?
Typically, Medicare will only pay for the most basic versions of equipment that it covers.
This means that if the upgrade is not strictly medically necessary, and prescribed by a doctor, it won’t be covered by Medicare.
Medicare may also not agree with the doctor, and refuse to cover the upgrade.
If your loved one still wants to get the upgrade, and they suspect that Medicare won’t pay for it, and the doctor won’t prescribe the device plus the upgrade, and your loved one is willing to pay for it themselves, they then need to have the supplier get them a waiver form called “Advanced beneficiary Notice”.
Your loved one must check the box on the form for upgrades, which states that they want upgrades and agree to pay their full costs if Medicare declines to cover it.
Medicare will cover the part that they consider medically necessary, and your loved one will pay their co-pay + their annual deductible if they haven’t already done so + the remaining costs of the upgrade from the basic model.
How do I get the DME I need with Medicare coverage?
Anyone who has Medicare Part B can get DME’s for their “home use if the equipment is medically necessary.
For someone claiming DME’s for their “home”, a hospital or nursing home which is providing Medicare coverage cannot qualify as their “home”, although a long-term care facility, such as an assisted living can qualify as “home”.
If you, or your loved one, is in a Skilled Nursing Facility or hospital, any necessary medical equipment is covered by Medicare Part A, as long as the facility purchases it from a Medicare-approved supplier. If the supplier accepts “assignment” Medicare will cover 80% of the cost of the DME, and you will cover the your 20% co-pay, and your annual deductible if it hasn’t already been met.
For those with Medicare Advantage Plans (which are private insurance policies sold by private companies), also referred to as Medicare Part C, you will be covered to the same degree as Medicare Parts A and B , and depending on the Plan it will it will cover you for extra areas.
You will need to check with your plan to find out everything they cover.
For those people who need DME’s for their own “home” (as defined above) here is the passage from Medicare’s own publication on what you have to do to get your DME.
The following passage is taken from 11045-medicare-coverage-of-dme.pdf.
If you need DME in your home, your doctor or treating practitioner (like a nurse practitioner, physician assistant, or clinical nurse specialist) must prescribe the type of equipment you need by filling out an order. For some equipment, Medicare may also require your doctor to provide additional information documenting your medical need for the equipment. Your supplier will work to make sure your doctor submits all required information to Medicare. If your needs and/or condition changes, your doctor must complete and submit a new, updated order.
Medicare only covers DME if you get it from a supplier enrolled in Medicare. This means that the supplier has been approved by Medicare and has a Medicare supplier number.
To find a supplier that’s enrolled in Medicare, visit Medicare.gov/ supplierdirectory. Or, call 1-800-MEDICARE (1-800-633-4227).
A supplier enrolled in Medicare must meet strict standards to qualify for a Medicare supplier number. If your supplier doesn’t have a supplier number, Medicare won’t pay your claim, even if your supplier is a large chain or department store that sells more than just DME.
You can read or download the entire Medicare document here
I would add, that if you want to get the best deal, you must make sure that the supplier accepts “assignment” so that you are only paying a maximum of your Medicare co-pay, and if you haven’t already paid it, your annual Medicare Part B deductible.
If Medicare won’t cover my DME’s, can Meidicaid help me ?
Medicaid is different from Medicare in that it is part Federal and part state run. For this reason there are a large number of programs and they can vary greatly from state to state.
All states have Medicaid long term care programs, or “institutional” Medicaid, where the residents care, and all they need is covered by Medicare-approved nursing homes. Any equipment needed is handled within their system.
Medicaid will also pay for home medical equipment, and will often cover 100% of the cost. Medicaid is however for people with extremely low income, mainly the elderly and the disabled, but also low income families.
The term “home” for Medicaid can be –
- your loved one’s home
- your loved one’s family home
- a group home
- an assisted living facility
- a custodial care facility
Medicaid has programs which are designed to help people stay residing in their homes, so that they don’t have to go into nursing homes which can cost the state far greater amounts of money.
These programs are called Home and Community Based Services (HCBS), Waivers, or 1915 Waivers. The programs will vary from state to state, but most allow for a wide range of DME’s.
There are certain waivers which permit what is called Consumer Direction which, simply put, means the beneficiary is allocated a budget which they may administer themselves to cover their needs. The budget can be spent on items including durable medical equipment.
Another Medicaid program called Money follows the person which was designed to help people leave nursing facilities and to return to live in their homes or assisted living facilities. DME’s which are needed for the process to happen are bought by the program.
Getting DME’s as a Veteran
If your loved one is a veteran, the Department of Veterans’ Affairs has many different grants, programs and forms of financial assistance which will help to cover the cost of DME’s and also Home Care Supplies.
Veterans are entitled to receive healthcare under the VA Medical Benefits Package. The law provides that the VA has to provide hospital care and outpatient care services, to eligible veterans that are defined as “needed.” The VA defines “needed”as a care or a service which promotes, preserves or restores health.
Your loved one can find out about their local VA Medical Centers and different clinics and offices in each state here
Below are just some of the different forms of assistance for you to look at if your loved one is a veteran.
Will cover DME’s which are deemed medically necessary by a doctor. Generally, it does not cover those in nursing homes as the nursing home usually provide DME’s as part of their coverage.
Veterans Directed Home and Community Based Services
These programs are designed to help eligible veterans to stay in there homes, or the community, and to avoid moving into nursing homes, by giving participants a care budget which they can manage, and spend, on care to cover their needs, including purchasing DME’s.
If the veteran is enrolled in one of these programs it replaces the care they can get from the VA Health Care system.
To participate the
ChampVA for Life
This is a Veterans’ Affairs health insurance program for the 65’s and over, and who are family members of veterans who were permanently disabled, or who died in the course of their duties.
ChampVA for Life will cover the beneficiary’s Medicare co-payments and deductibles.
Are there any other forms of assistance I can get to help with DME’s
Here are some examples of other State Programs which can help with getting DME’s
- Assistive Technology Projects
- Non-Medicaid State programs for the Elderly
- Protection and Advocacy Programs – they will help contest claims which have been denied
To sum up, the most important aspect of getting coverage for your loved ones DME’s is to make sure that you check that the supplier is a Participating Supplier who accepts “assignment”.
This means that you will pay the least amount of money possible with your Medicare coverage i.e. only the 20% co-payment and if you haven’t already paid it your annual deductible.
If you order something with out “assignment” you will be expected to pay the difference in price between the Medicare-approved price and the suppliers price, whatever that may be, plus your 20% co-payment of the Medicare- approved price and if you haven’t yet paid it, your annual deductible. The supplier can charge what he wants in this case.
So always check that the Medicare-approved suppliers accept “assignment” before you order.
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