What DME Is Not Covered By Medicare ?
What DME is not covered by Medicare ? Only DME which is prescribed as “medically necessary” by a Medicare-enrolled by physician, or treating practitioner, and acquired from a Medicare-enrolled supplier, is covered by Medicare for use in the home.
Contents Overview & Quicklinks
What is durable medical equipment ?
Medicare’s definition of Durable Medical Equipment is –
“Durable Medical Equipment is reusable medical equipment like, walkers, wheelchairs, or hospital beds”
Durable medical equipment is medical equipment which is able to withstand repeated use over a sustained period of time.
Medicare doesn’t, in general, cover medical supplies as they are usually disposable not reusable – there are exceptions to this, where the supplies are need in combination with DME which are covered.
DME for use in the home is covered by Medicare Part B, only if –
- it is prescribed as “medically necessary” by a Medicare-enrolled Physician “or treating provider (like a nurse practitioner, physician assistant, or clinical nurse specialist)”
- certain DME may demand extra documentation of the medical necessity of the equipment. Source : https://www.medicare.gov/Pubs/pdf/11045-Medicare-Coverage-of-DME.PDF
- the equipment must also be acquired (purchased or rented), through a Medicare-enrolled supplier to qualify for coverage
Medical equipment used in skilled nursing facilities, including DME for short term stays, is covered by Original Medicare Part A (hospital care).
Medicare’s basic criteria for DME
Durable medical equipment has to meet these following 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
- 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.
Equipment which Medicare considers to be “not primarily medical in nature”, “for comfort”, “for convenience” or a “non-reusable supply” will not be covered.
These would be items such as –
- bed wedges
- bed alarms
- air conditioners
- space heaters
- raised toilet seats
- shower chairs
Does Medicare cover bathroom equipment ?
Most bathroom safety equipment is not considered “medically necessary” and, as such, won’t be covered by Medicare Part B.
Bathroom safety items such as –
- grab bars
- raised toilet seats
- shower and bath chairs
- bathtub lifts
All the above are considered to be “comfort items”, as well as “not primarily medical in nature” and are not covered as DME by Medicare Part B.
If you are interested in Medicare, Medicaid and other funding available for bathroom safety equipment, I have an extensive article here.
For those of you enrolled in Medicare Advantage plans (also known as Medicare Part C), there is good news, as new benefits will be allowed under those policies, as of the end of 2020, so some items on the list below will be available to you.
In 2019, in a move to increase the competitiveness of Medicare Advantage plans, the Centers for Medicare & Medicaid released the following information-
Beginning in 2019, Medicare Advantage plans can now offer supplemental benefits that are not covered under Medicare Parts A or B, if they diagnose, compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.
Source: “CMS finalizes Medicare Advantage and Part D payment and policy updates to maximize competition and coverage” April 1, 2019. You can read this on the CMS.gov website here.
It has been hinted that by the end of 2020 some Medicare Advantage plans may be offering new benefits for bathroom equipment, or modifications, in their plans.
Air conditioners for people with respiratory illnesses, and transport for shopping for the elderly and disabled with mobility issues and who are unable to get the food they need, have also been suggested as new benefits on some Advantage plans.
Does Medicare cover exercise equipment ?
Medicare Part B does not offer any coverage of exercise equipment, as it is considered not primarily medical in nature.
Medicare Part B does however offer coverage for physical and occupational therapy treatments.
Medicare Advantage Plans do sometimes have coverage for exercise programs, but this will depend on the individual plans.
You may be able to get funding for exercise equipment from Medicaid and other state funding sources.
If you want to learn more you can read my full article about Medicare and exercise equipment, and where you will find out about the guidelines for physical and occupational therapy treatments using exercise equipment, and where you may actually be able to find exercise equipment for free. You can read that article here.
Medicare Free Supplies
Medicare coverage does not offer any “free” supplies, but on certain supplies and durable medical equipment Medicare will offer coverage of up to 80% of the cost, so long as you are enrolled in Medicare Part B, and you qualify under their guidelines.
Medicare does not cover supplies which are disposable for use in the home, such as gauze, incontinence pads or bandages, unless the supplies are being used in conjunction with a piece of durable medical equipment which does qualify.
Medicare does offer coverage to some medical supplies as durable medical equipment.
Medicare DME documentation requirements
Medicare may require any parts of the beneficiary’s medical records regarding the history of a beneficiary’s condition, physical examinations, diagnostic tests, summary of findings, diagnoses, treatment plans, that support the case for medical necessity of the DME, alongside statements of the anticipated benefits and outcomes due to the use of the DME.
This record, as well as the office records of the physician, can also include records from nursing homes, hospitals, home health agencies, and other health care professionals.
The records are to accompany the Certificate of Medical Necessity, as that doesn’t provide sufficient documentation of medical necessity.
For items such as hospital beds a valid written order prior to delivery is required.
List of DME typically not covered by Medicare
Please note that this list only covers items not covered by Medicare Parts A and B, otherwise known as Original Medicare.
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
List of DME 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’s sake, I have listed those items here as well.
Legally Medicare Advantage Plans, which are run by private companies, 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 home bound and the pool is medically needed. If your loved one isn’t home bound, 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 are covered by Medicare, do I have to pay anything myself ?
Typically, if you have a prescription for your DME from a Medicare-enrolled doctor, stating that your DME is “medically necessary” according to the Medicare guidelines, Original Medicare Part B will cover 80% of the cost of your DME.
You will pay your 20% co-payment and, if it applies, your annual deductible.
But 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 such a 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 (which can be up to 15% more), instead of just the 20% co-payment of the Medicare-approved price.
How can I get the best deal on Medicare covered DME
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 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 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 Medicare Advantage Plan, you will need to check with your plan.
Can I upgrade my DME ?
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 an 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 for their “home use” if the equipment is medically necessary.
For someone claiming DME 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 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 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 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 doesn’t cover my DME, can Medicaid help me ?
Medicaid is different from Medicare in that it is part Federal and part state run.
For this reason, there are many 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 required 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 home
- your family home
- a group home
- an assisted living facility
- a custodial care facility
Medicaid has programs which are designed to help people to remain living 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.
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, was developed to help people to leave nursing facilities and to return to live in their homes, or assisted living facilities.
The program has since started to provide funding to individual states to set up their own versions of the program, either by setting up new programs, or by adapting existing ones.
If you wish to see the HCBS Waivers, 1915 Waivers, HCBS Programs and the Money Follows The Person Programs for seniors which are available in your state, I have an article with a list of what is available in each state, along with links to the different program websites. The Article also has lists of all the PACE programs which are for All-inclusive care in the home, by state – “Medicaid Home and Community Based Services Waivers and Programs For Seniors Listed By State”.
Getting DME as a Veteran
If you are a veteran, the Department of Veterans’ Affairs has many grants, programs and forms of financial assistance, which will help to cover the cost of DME 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.
You can find out about their local VA Medical Centers and different clinics and offices in each state here.
Below are just some different forms of assistance for you to look at if your loved one is a veteran.
Tricare for Life –
This is a supplemental program to Medicare Parts A and B, which will cover the 20% co-pay when you get DME through Medicare.
You would need to be enrolled in Medicare to get this
Will cover DME which are deemed medically necessary by a doctor.
Generally, it does not cover those in nursing homes, as the nursing home usually provide DME as part of their coverage.
Veterans Directed Home and Community Based Services
These programs are designed to help eligible veterans to stay in their homes, or the community, and to avoid moving into nursing homes.
This is done by giving participants a care budget which they can manage, and spend on care to cover their needs, including purchasing DME.
If the veteran is enrolled in one of these programs, it replaces the care they can get from the VA Health Care system.
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
Here are some examples of other State Programs which can help with getting DME –
- 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 DME 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 without “assignment” you will be expected to pay the difference in price between the Medicare-approved price and the supplier’s price (if there is one), 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 up to 15% more than the Medicare-approved price for equipment if he is not a Medicare-enrolled “Participating” supplier.
So, always check that the Medicare-approved suppliers accept “assignment” before you order.
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I’m Gareth and I’m the owner of Looking After Mom and Dad.com
I have been a caregiver for over 10 yrs and share all my tips here.
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