What Equipment Does Medicare Pay For?

What Equipment Does Medicare Pay For

Medicare Part B covers durable medical equipment costs, but it must be medically necessary and prescribed by a qualified healthcare provider.

Original Medicare includes two parts: A and B. Medicare Part A covers inpatient services received in a hospital or skilled nursing facility (SNF) as well as hospice care. Medicare Part B provides coverage for doctor visits, lab work, durable medical equipment (DME), and more. So, what equipment does Medicare pay for? The list is long, but generally speaking, Part B helps pay for items deemed medically necessary by your healthcare provider.

What Is Durable Medical Equipment?

As the name implies, durable medical equipment holds up against repeated or prolonged use. According to Medicare, it must be medically necessary, intended for home use, and of little use to someone unless they are sick or injured. Finally, durable medical equipment usually has an expected lifespan of 3 or more years.

DME must be prescribed by a medical provider, such as a doctor, nurse practitioner, physician assistant, or clinical nurse specialist.

Other Medical Equipment Covered by Medicare

Medicare Part B also covers the following medical equipment:

  • Prosthetic devices: May include ostomy supplies, urinary catheters, breast prostheses following a mastectomy, and prescription lenses following cataract surgery
  • Orthotics: May include arm, back, leg, and neck braces
  • Therapeutic shoe inserts: Patients who have diabetes and diabetic foot disease may qualify for therapeutic shoes or inserts ordered by a qualified doctor, such as a podiatrist

Medicare Part B may also cover artificial arms, legs, and eyes.

How Does Medicare Cover Durable Medical Equipment?

Medicare Part B covers durable medical equipment. The Part B deductible applies and beneficiaries pay 20 percent of the Medicare-approved amount.

Different types of equipment are covered in different ways, meaning some items are purchased while others are rented. Typically, inexpensive items, such as walkers and canes, are purchased outright. Costlier items are usually rented. For details regarding your particular item, call 1-800-MEDICARE (633-4227) or TTY 1-877-486-2048.

Durable medical equipment is only covered when procured from an enrolled supplier who accepts assignment.

Covered medical equipment is intended for use in the home. If you require DME while receiving inpatient care at a skilled nursing facility (as provided by Medicare Part A), said equipment is provided by the SNF.

When Does Medicare Cover Durable Medical Equipment?

Medicare covers durable medical equipment when it has been prescribed by a qualified healthcare provider who deems it medically necessary for use in the home. Both the medical provider and DME supplier must be enrolled in Medicare.

How Much Does Durable Medical Equipment Cost with Medicare?

Your costs for durable medical equipment under Medicare are 20 percent of the Medicare-approved amount. This assumes both your medical provider and DME supplier participate in Medicare.

If you have Medicare Supplement Insurance, commonly known as Medigap, your plan may cover the 20 percent coinsurance for DME.

What Durable Medical Equipment Does Medicare Cover?

Medicare covers a wide variety of durable medical equipment. Covered items include (but are not limited to):

  • Blood sugar monitors and test strips
  • Canes, crutches, and walkers
  • Commode chairs
  • Hospital beds
  • Infusion pumps and supplies
  • Manual wheelchairs and power mobility devices (wheelchairs and scooters) when required inside the home
  • Nebulizers and CPAP
  • Oxygen equipment and accessories
  • Patient lifts
  • Pressure reducing beds and mattresses

Medicare.gov provides a more comprehensive list of covered DME.

Does Medicare Advantage Cover Durable Medical Equipment?

Also known as Medicare Part C, Medicare Advantage plans must provide the same benefits as Medicare Parts A and B. However, details like out-of-pocket costs are determined by the insurance company that provides the plan. For details and costs related to durable medical equipment, call your Medicare Advantage plan and ask to speak to utilization management.

Medicare Part D provides prescription drug coverage. It is not part of Original Medicare and does not cover durable medical equipment.

How Do I Get Durable Medical Equipment?

The first step is to talk to your provider, since DME must be prescribed by a qualified healthcare professional. Your provider must accept assignment or Medicare will not cover services, even if they're medically necessary.

Make sure the DME supplier is enrolled in Medicare. If they aren't, Medicare will not pay your claim. Next, verify that the supplier accepts assignment. Providers may be enrolled in Medicare but not accept assignment, which means they may charge more than the Medicare-approved amount. Medicare.gov/supplier directory is a good place to start. You can also call 1-800-MEDICARE.

What Does "Accepts Assignment" Mean?

Medicare negotiates rates with providers, which may be (and usually are) significantly lower than the rates those providers charge non-Medicare patients. A provider who "accepts assignment" agrees to provide services at the Medicare-approved rate.

If a DME supplier accepts assignment, it is known as a participating supplier. Providers who do not accept assignment can charge any amount they choose. What's more, you'll likely have to pay the entire bill at the time of purchase. The supplier may bill Medicare on your behalf, and Medicare may reimburse you its share of the Medicare-approved amount.

Some DME suppliers are enrolled in Medicare but do not accept assignment. In this case, ask if the supplier will accept assignment for your claim. If not, be prepared for Medicare to pay only 80 percent of its approved amount. That leaves you footing the bill for the remainder, which may be significantly more than the standard 20 percent of the Medicare-approved amount.

For example, if the Medicare-approved amount is $60 but the DME supplier charges $100, Medicare will reimburse 80 percent of $60, or $48. That leaves you paying more than half of the cost instead of the Medicare Part B 20 percent coinsurance ($52 versus $12).

Does Medicare Ever Pay for a Power Wheelchair or Scooter?

If your provider asserts that you have a medical need for a power wheelchair or scooter, Medicare will likely cover it. Talk to your doctor and Medicare to be sure.

Will Medicare Pay to Replace Lost or Damaged Durable Medical Equipment?

If DME or other medical equipment is lost or damaged due to an emergency after Medicare pays for it, repairing or replacing it may be covered. Call 1-800-MEDICARE for more information. If you have a Medicare Advantage plan, please contact your plan for more details.

Do I Buy or Rent Durable Medical Equipment?

Most durable medical equipment is rented, not purchased outright. Your DME supplier will know for sure, assuming they are enrolled in Medicare.

Medical equipment that you buy is generally expected to last for 5 years. Medicare typically covers repairs, though, at the same 80 percent rate.

Some rented items may be purchased if you need them for more than a few months. Or, some items, like oxygen equipment, can be rented for 3 to 5 years. Monthly payments include 80 percent from Medicare plus your 20 percent out-of-pocket. Once you no longer require the equipment, the DME supplier collects it.

Medicare Coverage for Oxygen Equipment and Supplies

Oxygen equipment is rented. Payments last up to 36 months, although the patient may keep the equipment and continue getting related supplies for up to 5 years. If you still require oxygen equipment after 5 years, you may enter a new agreement with either the same DME supplier or a new one.

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