Medicare's Durable Medical Equipment (DME) Benefits

Medicare does pay for durable medical equipment, but the devil is in the details.

Do Medicare's Benefits Include Home / Durable Medical Equipment?

The short answer is, Yes, Medicare does pay for Durable Medical Equipment (DME)! However, prior to a thorough discussion of the details, it is important to be aware of the different types of Medicare coverage, as the benefits differ based on one’s type of coverage. Medicare Part A is hospital insurance and Part B is for medical outpatient services. (Part A and Part B is sometimes referred to as Original Medicare). Part C (also called Medicare Advantage or MA) combines Part A and Part B and generally offers additional benefits, such as vision and dental. Part C is sold by private companies, rather than provided by the government. Medicare Part D is for prescription drugs and is not relevant to the discussion on DME.

Part A covers medical equipment for individuals who are in a skilled nursing facility or in the hospital. If the equipment is medically necessary and purchased from an approved supplier, Medicare Part A will pay for 80% (if one’s annual deductible has been met) of the allowable amount for any specific item. The individual or their supplemental insurance is responsible for paying for the remaining 20% and any amount over the allowable limit.

Part B pays for medical equipment to be used in one’s home for most Medicare recipients, even if they are not confined to their home. In addition to one’s private home, a personal care residence, such as an assisted living facility, can be considered one’s “home”. A nursing home does not qualify as one’s “home”. Home medical equipment must be medically necessary, prescribed by one’s physician, and purchased from a Medicare-approved supplier. Medicare Part B pays for 80% (if one’s annual deductible has been met) of the allowable purchase price. The individual or their supplemental insurance is responsible for the remaining 20% and any amount over the allowable limit.

Part C, which as mentioned previously, is also known as Medicare Advantage Plans, is required by law to provide, at a minimum, the same coverage as Part A and Part B. Therefore, if one has Medicare Part C, their plan will pay at least 80% of the allowable limit for durable medical equipment.

 

Types of DME Covered by Medicare

It is best to think of Medicare’s durable medical equipment coverage as having 2 levels: DME that is covered when determined to be medically necessary and DME that is never covered despite being medically necessary. For example, grab bar rails may be completely necessary for an individual, but Medicare does not consider them to be medical equipment and therefore will not cover the cost.

Durable Medical Equipment vs. Home Care Supplies
Commonly, persons cannot make the distinction between medical equipment and home care supplies. Medicare has a completely different policy for home and/or disposable medical supplies as opposed to durable, multiple use equipment.  Read more.

The table below lists commonly requested durable medical equipment, if it is covered, and if not, Medicare’s reason for denying coverage. This list is by no means exhaustive. Rather, it is meant to provide the reader with a sense of Medicare’s logic so that it may be applied to one’s own situation.

Medicare's 2018 Durable Medical Equipment Coverage

Item Type

Medicare Coverage Policy / Denial Reason

Air Cleaners / Conditioners

Environmental control equipment; not primarily medical in nature

Air Fluidized Beds

Covered

Bathtubs (Walk In)

Not covered; not primarily medical in nature. Find other assistance.

Beds (Oscillating)

Institutional equipment; inappropriate for home use

Blood Glucose Analyzers

Unsuitable for home use

Blood Sugar Monitors

Covered

Catheters

Nonreusable disposable supply

Canes

Covered

Commode Chairs

Covered

Continuous Passive Motion Machines

Covered

Crutches

Covered

Dehumidifiers and humidifiers

Environmental control equipment; not primarily medical in nature

Diabetic Test Strips

Covered

Diathermy Machines

Inappropriate for home use

Disposable Sheets

Nonreusable disposable supplies

Electrical Stimulation for Wounds

Inappropriate for home use

Elevators

Convenience item; not primarily medical in nature

Esophageal Dilators

Physician instrument; inappropriate for patient use

Exercise Equipment

Not primarily medical in nature

Fabric Supports

Nonreusable supplies; not rental-type items

Grab Bars

Self-help device; not primarily medical in nature

Heat and Massage Foam Pads

Not primarily medical in nature; personal comfort item

Home Oxygen Equipment

Covered

Hospital Beds

Covered. Other assistance for hospital beds.

Incontinent Pads

Nonreusable supply; hygienic item

Infusion Pumps

Covered

Injectors (hypodermic jet)

Not covered self-administered drug supply; pressure powered devices

Irrigating Kits

Nonreusable supply; hygienic equipment

Massage Devices

Personal comfort items; not primarily medical in nature

Nebulizers

Covered

Overbed Tables

Convenience item; not primarily medical in nature

Powered / Electric Wheelchairs

Covered

Patient lifts

Covered

Preset Portable Oxygen Units

Emergency, first-aid, or precautionary equipment; not therapeutic

Raised Toilet Seats

Convenience item; hygienic equipment; not primarily medical in nature

Spare Tanks of Oxygen

Convenience or precautionary supply

Sleep Apnea Devices

Covered

Speech Teaching Machines

Education equipment; not primarily medical in nature

Stair Lifts

Not covered; not medical in nature.  Find other assistance.

Suction Pumps

Covered

Telephone Alert Systems

Emergency communications systems and not diagnostic or therapeutic

Toilet Seats

Not medical equipment

Traction Equipment

Covered

Treadmill Exercisers

Exercise equipment; not primarily medical in nature

Walkers

Covered

Walk In Bathtubs

Not covered; not primarily medical in nature. Find other assistance.

Wheelchairs (Manual & Power)

Covered by Part B

 

What are Medicare Suppliers vs. Medicare Participating Suppliers?

To ensure that Medicare beneficiaries pay the minimum out-of-pocket for durable medical equipment, it is important to distinguish between Medicare Suppliers and Medicare Participating Suppliers. 

Medicare Participating Suppliers are suppliers that have agreed to accept “assignment”.  Assignment is the Medicare approved price for a specific item of DME. Purchasing from a Medicare Participating Supplier ensures the individual will not pay more than the 20% co-pay of the Medicare approved price for an item. This is usually the least expensive route for Medicare beneficiaries.

Medicare Suppliers are enrolled in Medicare’s program, meaning they will accept Medicare as a form of payment, but they don’t have to accept “assignment”. This means they have the flexibility to set their own prices, but they can still accept “assignment”. By using a Medicare Supplier, the individual may or may not spend the least amount out-of-pocket.

There are also DME suppliers that are not approved by Medicare. If one purchases from these suppliers, Medicare will not pay any portion of the cost.

 

Finding Medicare Approved Suppliers

Medicare provides a searchable database of all approved suppliers. One can search by item type and by zip code. Results can be sorted to show Participating Suppliers first. Search for Medicare Approved Suppliers.

 

Renting vs. Buying Medical Equipment with Medicare

Typically, the decision to rent versus buy is not made by the individual. Instead, Medicare makes this decision. In most cases, Medicare will rent the equipment and will only purchase inexpensive DME or equipment that must be custom made. In many cases, renting works to the individual’s benefit, as they do not have to spend additional money should an item break or require repairs. The Medicare-approved supplier will inform the individual if the item they require is available for rent or purchase.

 

What are Medicare’s Allowable Limits for Home Medical Equipment?

Medicare has determined the maximum dollar amount their Participating Suppliers are allowed to charge for any particular item of home medical equipment. This is referred to as the “allowable limit”. Medicare updates this regularly and communicates this information to all their suppliers.

Ensuring suppliers only charge the allowable limit is a self-regulating process in that Medicare will only reimburse suppliers the allowed amount. If suppliers attempt to bill for more than the allowable limit, they run the risk of not being reimbursed at all.

 

What is Upgraded Equipment and How Does One Purchase it with Medicare?

Sometimes suppliers will reduce the cost of upgraded equipment in order to make a sale.

Typically, when Medicare approves an item of durable medical equipment, they will approve only the most basic item available. For example, Medicare may approve the purchase of a walker, but not one with wheels and a hand brake; this would be considered “upgraded equipment”.

It is possible that an upgrade is medically necessary, and if so, Medicare will pay for its portion of the upgrade cost. One’s prescription must state specifically the medical reason for why an upgrade is necessary. For example, the individual does not have the physical strength or balance required to lift a standard walker, and therefore, one with wheels is required.

Upgrades are also possible simply because the individual prefers a different model. However, in this situation, Medicare will not pay the additional cost. Instead, the individual or supplier is responsible for making up the difference. Medicare has developed a specific process for this situation to help avoid fraud and abuse. When an upgrade occurs, the supplier provides the individual with a document called an Advance Beneficiary Notice of Noncoverage (ABN), which requires their signature. The ABN states the nature of the upgrade and that the individual is responsible for the additional cost. It is worth noting that sometimes suppliers will reduce the cost of the upgraded equipment in order to make a sale. Purchasers should not hesitate to ask for this reduction. The supplier then provides the ABN to Medicare when requesting reimbursement.