What Qualifies As Durable Medical Equipment ?

If you’re a caregiver to an elderly parent, or loved one, you will, I’m sure, be constantly on the look-out for different equipment and supplies that will make their life easier. To get your purchases covered by Medicare or Medicaid, they’ll need to qualify as Durable Medical Equipment.

 
Durable Medical Equipment is generally considered to be medical equipment which –

• is “durable” – able to withstand repeated use over a sustained period of time
• is used for a medical reason – it must be medically necessary, and not just to make things more comfortable
• is not something which is usually useful to a person who is not sick or injured
• expected to have a lifetime of at least 3 years

Even if the equipment qualifies as a DME, if your loved one doesn’t have a doctor’s, or treating practitioner’s, prescription stating that the device is a medical necessity it will not get coverage from either Medicare, or Medicaid.

Medicare covered DME

I am going to start with Medicare covered DME as the rules are only slightly different from Medicaid, but it is Medicaid which varies, and not Medicare.

Medicaid has a more flexible and wider range of DME than Medicare due to its funding, which is both federal and state level, which I will outline once I have dealt with Medicare.

DME, typically covered by Medicare

To qualify for these DME under Medicare, you will need to have Original Medicare Parts A and B to qualify.

• Part A (Hospital Insurance) covers Durable Medical Equipment for beneficiaries who are living in skilled nursing facilities
• Part B (Medical Insurance) covers Durable Medical Equipment for those living at “home”

To find a Medicare supplier in your area, you can use this link at Medicare.gov

If you don’t find the DME you are looking for in my list of included Medicare DME below, you can use this link to Mediace.gov 

List of DME typically covered by Medicare

Air-Fluidized Bed
Alternating Pressure Pads and Mattresses
Audible/visible Signal Pacemaker Monitor
Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
Bead Bed
Bed Side Rails – if you own a hospital bed which takes side rails, but they did not come with the bed, medicare will cover these
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)
Commode chairs
Continuous passive motion (CPM) machines
Continuous Positive Pressure Airway Devices, Accessories and Therapy
Crutches
Cushion Lift Power Seat
Defibrillators
Diabetic Strips
Digital Electronic Pacemaker
Electric Hospital beds
Gel Flotation Pads and Mattresses
Glucose Control Solutions
Heat Lamps
Hospital beds
Hydraulic Lift
Infusion pumps and supplies (when necessary to administer certain drugs)
IPPB Machines
Iron Lung
Lymphedema Pumps
Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
Mattress
Medical Oxygen
Mobile Geriatric Chair
Motorized Wheelchairs
Muscle Stimulators
Nebulizers and some nebulizer medications (if reasonable and necessary)
Oxygen equipment and accessories
Oxygen Tents
Patient Lifts (a medical device used to lift you from a bed or wheelchair)
Percussors
Postural Drainage Boards
Quad-Canes
Respirators
Rolling Chairs
Safety Roller
Seat Lift
Self-Contained Pacemaker Monitor
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
Sitz Bath
Steam Packs
Suction pumps
Traction equipment
Ultraviolet Cabinet
Urinals (autoclavable hospital type)
Vaporizers
Ventilators
Walkers
Whirlpool Bath Equipment – if you are home bound and the pool is medically needed. If you aren’t home bound, Medicare will cover the cost of treatments in a hospital.

DME not typically covered by Medicare

Adult Diapers
Air Cleaners
Air Conditioners
Alcohol Swabs
Augmentative Communication Device
Bathroom Aids
Bathtub Lifts
Bathtub Seats
Bed Bath
Bed Boards
Bed Exit Alarms
Bed Sensor Pads
Bed Lifter
Beds – Lounge
Bed Wedges
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
Communicator
Contact Lenses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens
Dehumidifiers
Dentures
Diathermy Machines
Disposable Bed Protectors
Disposable Sheets
Door Exit Alarms
Easygrip Scissors
Elastic Stockings
Electrical Wound Stimulation
Electrostatic Machines
Elevators
Emesis Basins 
Esophageal Dilators
Exercise Machines
Exit Alarm Mat
Eye Glasses – Medicare helps pay for corrective lenses if you have cataract surgery to implant an intraocular lens.
Fall Alarms
Fans
Fabric Supports
Fomentation Device
Grab Bars
Grabbers
Gauze
Hearing Aids
Heat and Massage Foam Cushion Pad
Heating and Cooling Plants
Home Modifications
Humidifiers – not room humidifiers
Incontinence Pads
Injectors (hypodermic jet pressure powered devices for Insulin injection)
Irrigating Kits
Insulin Pens
Massage Equipment
Motion Sensors
Motion Sensor Exit Systems with Pagers
Needles
Oscillating Beds
Over bed Tables
Paraffin Bath Units (if not Portable)
Parallel Bars
Portable Room Heaters
Portable Whirlpool Pumps
Preset Portable Oxygen Units
Pressure Leotards
Pressure Stockings
Pulse Tachometer
Pull String Alarms
Raised Toilet Seats
Ramps
Reading Machines
Reflectance Colorimeters
Sauna Baths
Special TV Close Caption
Speech Teaching Machines
Stair Lifts
Standing Table
Support Hose
Surgical Face Masks
Surgical Leggings
Syringes
Telephone Alert Systems
Television Assistive Listening Devices
Telephone Arms
Toilet Seats
Treadmill Exercisers
Walk in Bathtubs
Wheelchair Lifts
Whirlpool Pumps
White Canes
Wigs

If this was not enough information, you can read a full article with greater detail on what DME’s are not covered by Medicare here.

What is the purchasing procedure for Medicare covered DME ?

To move ahead with a DME purchase for home use covered by Medicare, you will need –

•  to be enrolled in Medicare Part B
•  a prescription signed by their Medicare enrolled doctor, or treating practitioner, which states the equipment is a medically necessary
• purchase the medical equipment from a Medicare-enrolled supplier

If the doctor and the suppliers are not Medicare-enrolled, Medicare will not cover any of the payment.

A hospital or nursing home (skilled nursing facilities – SNF’s) cannot qualify as a “home” for Original Medicare Part B, if you are claiming equipment for use at “home”. However, you will be covered under Medicare Part A.

A long-term care facility, such as an assisted living facility, can qualify as a “home” for you under Original Medicare part B.

Medicare’s definition of a home ?

• it can be your own home
• it can be the family home
• it can be in the community, such as assisted living

What do you do now you have the prescription ?

If Medicare accepts to cover your DME, and you used a Medicare-enrolled “participating” supplier who accepts assignment, then –

• you will pay your co-pay of 20% of the Medicare-approved price,
• Original Medicare will pay the remaining 80% of the Medicare-approved price
• if you have not yet met their annual deductible, you will have that to pay as well

Why do you need, to find a Medicare-enrolled “participating” supplier ?

If you don’t use a Medicare-enrolled “participating” supplier, you may end up paying way more for the equipment than you would otherwise.

Here’s why

Firstly, you have to use a Medicare-enrolled supplier, as these are the suppliers who have accepted to take payment from Medicare, and they have also met all of Medicare’s required standards of service.

But it goes further…..

Medicare-enrolled suppliers fall into two different groups –

• Medicare Suppliers
• Medicare “Participating” Suppliers

Medicare “Participating” Suppliers are those suppliers who have agreed to what is known as “assignment” – this obliges them to only charge the Medicare-approved price.

So

• the Medicare-enrolled “Participating” supplier can only charge you the 20% co-pay of the Medicare-approved price
• if you have not met your annual Medicare deductible for the year in case, you will have to pay this as well

If the supplier is not a “Participating” Supplier ?

A Medicare-enrolled supplier who is not a “Participating” Supplier, has –

• agreed to take payment from Medicare at the level of the Medicare-approved price
• but can charge you up to 15% more than the Medicare-approved price for equipment

And the result –

• Medicare will pay the supplier 80% of the Medicare-approved price for the DME
• You will pay the supplier the 20% co-pay of the Medicare-approved price + the difference in price between the Medicare-approved price and the supplier’s price
• And you will also have to pay your annual Medicare deductible if you haven’t yet done so.

So make sure you are using a Medicare-enrolled “Participating” Supplier, and always make sure the supplier accepts “assignment”.

What qualifies as a DME if your parent is in a skilled nursing facility ?

If you are being cared for in a Skilled Nursing Facility or hospital, any necessary DME is covered under Medicare Part A (Hospital Insurance). The facility is responsible for providing any required DME for up to 100 days.

What DME do Medicare Advantage plans cover ?

Medicare Advantage Plans are offered by Medicare-approved private companies contracted to provide at least the same coverage as to Original Medicare Parts A and B.

By law, Advantage plans must provide equal coverage for DME to Original Medicare, and will often have extra DME benefits, such as hearing and visual equipment coverage under their plans.

Medicare Advantage Plan providers will require you to use health care providers and suppliers who participate in their networks.

If you don’t use a health care provider or supplier in your plan’s network,  you may find that you will have no coverage and be burdened with the entire cost.

What qualifies as a DME for Medicaid ?

A state can have a number of different Medicaid programs, Home Based Care Services and waivers, each with different eligibility guidelines, resulting in hundreds of programs for Medicaid across the US.

Because the different states are also contributing funds to the programs, as well as the federal funding, what is considered durable medical equipment can vary from state to state, and even program to program.

Medicaid and state programs for in the home

Medicaid programs which are for individuals in their homes, rather than in skilled nursing facilities, are called “Home and Community Based Services”, “Waivers” or “1915 Waivers”.

The programs, or waivers, have been developed to help individuals maintain their independence in their homes, and to provide the care services and equipment needed.

They will pay for “home medical equipment”, and unlike Medicare, often cover 100% of the cost.

This is the area where what qualifies as a DME will vary the most, and these programs will have the greatest breadth of equipment that may be considered within the category.

The term “home”, for HCBS programs and waivers purposes, means the beneficiary must be in –

• their own home
• their family home
• a group home
• an assisted living facility
• a custodial care facility

Consumer Direction

Some state waivers allow for a system called Consumer Direction. The participant is given a budget for living their requirements, which they may spend under the guidance of a financial planner.

The budget can be used to buy durable medical equipment.

On a program with Consumer Direction if a walk in bathtub, grab bar, bath lift, or shower chair is considered a medical necessity, and is within the allotted budget, they may well be able to have one.

None of these would qualify under Medicare.

Money follows the person

The program Money follows the person was created to make it possible for the elderly to leave nursing facilities, and to return them to their homes, or assisted living facilities.

Durable medical equipment, which is required for the persons to return to their homes, is bought by the program.

If it is deemed  critical for you to have a certain piece of equipment to return home, and without which it would not be possible, or safe, the program will get it.

So again, what can qualify as a DME is broader than the range of equipment allowed under Medicare.

To find your State Medicaid State Agency

To get in touch with your State Medicaid Agency, click here.

Step 1 –

Once you have clicked on the link above, look for the section that I have outlined in red, in the image below.

Step 2 –

Select your state form the drop-down menu, and click on the button marked “GO”.

You will get all the contact info for your State Medicaid Agency.

How do you purchase equipment on Medicaid and state funded programs ?

For anything to qualify for Medicaid and state programs, you generally still have to –

• get your doctor, or therapist, to write a medical justification letter, making it clear the equipment is medically necessary
• contact a Medicaid-approved DME supplier, and give them the medical justification letter from the doctor, or therapist
• the supplier will need to fill out a Prior Approval Application
• the Prior Approval document is sent to the Medicaid state office  for approval or refusal
• if the request is unsuccessful, you will be notified as to why, and how you can  appeal the decision
• if the purchase of the equipment is approved, the supplier will have it delivered to you

Summary

For any Medical Equipment to qualify as Durable Medical Equipment for Medicare, it must be “medically necessary” and able to stand up to repeated use over a sustained period of time.

Medicare will also always buy the least expensive version it can of any equipment, so if your parent wants any upgrades from the basic model, they will have to pay the extra themselves.

The most important aspect of getting coverage for your loved ones DME is to make sure that you check that their doctor providing the prescription is Medicare-enrolled, and that the supplier is a Medicare-enrolled Participating Supplier who accepts “assignment”.

Medicaid is more flexible in what it counts as DME’s due to the nature of its funding and structure of programs and waivers on the state level.

Due to the fact that there are so many programs in all the different states, what a state will be willing to consider as a DME can vary considerably.

The above would be seen to be most true in the wide range of HCBS programs and waivers designed to keep people residing in their own homes by offering assistance for them to do so.