For many Medicare beneficiaries, durable medical equipment (DME) plays a crucial role in maintaining independence and quality of life. Whether it’s a walker, wheelchair, or oxygen equipment, understanding how Medicare covers DME can help you access the essential medical tools you need while managing out-of-pocket costs effectively.
If you’re new to the world of Medicare, let us help you understand the basics of Medicare, what durable medical equipment includes, and how Medicare can help cover the cost of these vital items.
Understanding Medicare: The Basics
Medicare is a federally funded health insurance program primarily for individuals aged 65 and older, and both younger and older individuals with certain disabilities
Medicare consists of different parts that cover various healthcare services:
- Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and limited home health services.
- Part B (Medical Insurance): Covers outpatient services, doctor visits, preventive care, and medically necessary durable medical equipment.
- Part C (Medicare Advantage): An alternative to Original Medicare (Parts A and B), offered by private insurers. Many plans also include extra benefits, such as dental, vision, and prescription drug coverage.
- Part D (Prescription Drug Coverage): Helps pay for prescription medications.
For durable medical equipment, Medicare Part B is the primary source of coverage, provided the equipment is medically necessary and prescribed by a doctor.
What is Durable Medical Equipment (DME)?
Durable medical equipment refers to medically necessary items that provide therapeutic benefits to individuals with illnesses, disabilities, or injuries. These items are intended for repeated use and are typically used in the home.
Common Examples of DME Covered by Medicare
- Wheelchairs and power scooters
- Walkers, canes, and crutches
- Hospital beds
- Oxygen equipment and supplies
- Continuous Positive Airway Pressure (CPAP) machines for sleep apnea
- Blood sugar monitors and test strips for diabetes
- Nebulizers and nebulizer medications
- Patient lifts
To be covered, the equipment must be durable, medically necessary, and used in the home (with some exceptions, such as mobility devices used outside).
Items Medicare Does Not Typically Cover as DME
Some equipment and supplies are not considered durable medical equipment under Medicare. These include:
- Items for comfort or convenience (e.g., air conditioners, humidifiers)
- Most disposable supplies (e.g., incontinence pads, bandages)
- Equipment for use outside the home unless medically necessary (e.g., stair lifts)
- Modifications to the home (e.g., wheelchair ramps, handrails)
How Does Medicare Cover the Cost of Durable Medical Equipment?
If your doctor determines that you need durable medical equipment, Medicare Part B will cover a portion of the cost under the following conditions:
- The Equipment Must Be Medically Necessary
- Your doctor must certify that the equipment is essential for your health condition
- A written prescription or order is required
- The Supplier Must Be Medicare-Approved
- Medicare only covers DME from suppliers enrolled in the Medicare program
- Using an out-of-network supplier may result in higher costs or denied coverage
- You Pay 20% of the Medicare-Approved Cost
- Medicare typically covers 80% of the approved cost, and you are responsible for the remaining 20% after meeting your Part B deductible
- Some Medicare Supplement (Medigap) plans may cover part or all of the 20% coinsurance
- Medicare May Rent or Buy the Equipment
- Some equipment (like wheelchairs) is rented monthly while others (such as blood sugar monitors) are purchased outright
- If renting, Medicare pays the supplier a monthly fee, and you are responsible for coinsurance
Medicare Advantage (Part C) and DME Coverage
Medicare Advantage plans must cover DME at least as well as Original Medicare (Part B), but they may have different supplier networks, approval processes, or cost structures. If you have a Medicare Advantage plan, check with your provider to confirm coverage details.
Maximize Your Medicare Coverage to Reduce Out-of-Pocket Costs
Medicare provides significant coverage for durable medical equipment, making it easier for beneficiaries to access essential medical tools that support their health and independence. However, to ensure coverage, it’s crucial to:
- Get a doctor’s prescription
- Use a Medicare-approved supplier
- Understand cost-sharing responsibilities
- Follow the necessary approval processes
By taking these steps, you can maximize your Medicare benefits and minimize out-of-pocket expenses for the durable medical equipment you need.
If you have any questions and need help getting your DME covered by Medicare in Texas, please reach out to our Medicare advisors. We’re here to help you make the right decisions, stay informed about your choices, and ensure you get the coverage you deserve.
Emily Trevino, Senior Managing Partner at Wise Insurance, leverages her extensive background in biology and business finance to master Medicare, health insurance, and retirement planning. With over a decade in the field, Emily has co-authored “Medicare Breakdown – The Alphabet Soup of Medicare,” marking her as a pivotal figure in insurance education. Her commitment extends through active participation in the National Association of Benefits and Insurance Professionals (NABIP) and speaking at major industry events. Emily’s drive for community service and personal resilience shines through her adventurous pursuits and dedication to societal well-being. Connect with Emily on LinkedIn to explore the future of informed insurance decisions.
