Medicare Coverage of DME

Medicare Coverage of DME (Durable Medical Equipment)

When it comes to staying healthy and independent, many Medicare beneficiaries rely on durable medical equipment (DME). Whether it’s a walker, a hospital bed, or a CPAP machine, understanding Medicare coverage of DME is essential for many.

In this post, we’ll break down what DME is, how Medicare covers it, and what clients should know to avoid costly surprises.

What Is Durable Medical Equipment (DME)

Durable Medical Equipment is defined as reusable medical equipment that is:

• Medically necessary for the patient’s health condition
• Able to withstand repeated use
• Primarily used for a medical purpose
• Appropriate for use in the home

Examples of common DME include:

• Wheelchairs and scooters
• Walkers and canes
• Hospital beds
• Oxygen equipment
• Blood sugar monitors and test strips
• CPAP machines and supplies

How Medicare Covers DME

Medicare Part B

Most DME is covered under Medicare Part B (Medical Insurance). Here’s how it works:

• Doctor’s Order Required: A physician or other Medicare-approved provider must prescribe the equipment.
• Approved Supplier: The equipment must be purchased or rented from a Medicare-approved supplier that accepts assignment.
• Cost-Sharing: The beneficiary pays 20% of the Medicare-approved amount after meeting the Part B deductible.

Those who have a Medicare Supplement plan may pay as little as $0 depending on the plan they have.

Some equipment is available for purchase, while other items are only available for rental. For rentals, Medicare usually pays the supplier monthly for up to 13 months, after which the beneficiary typically owns the equipment.

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Prior Authorization and Competitive Bidding

In some cases, Medicare requires prior authorization for certain high-cost or frequently abused items (like power wheelchairs). Additionally, in certain areas, Medicare runs a competitive bidding program for DME, meaning beneficiaries must use specific contracted suppliers to get full coverage.

Medicare Advantage and DME

Medicare Advantage (Part C) plans also cover DME, but:

• Networks and suppliers may be different from Original Medicare.
• Some plans require prior authorization for more types of equipment.
• Cost-sharing may vary (some plans may have lower copays or coinsurance).

Agents should always remind clients to check their plan’s provider directory and approval process before ordering DME.

Tips for Agents and Beneficiaries

• Verify Coverage First: Always confirm that the prescribing provider and supplier are Medicare-approved.
• Check the Need: Make sure there’s documentation showing the equipment is medically necessary.
• Understand Costs: Explain that clients will still owe 20% coinsurance under Part B unless they have Medigap or other supplemental coverage.
• Watch for Scams: DME fraud is common – warn clients not to accept unsolicited equipment or offers.

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Durable Medical Equipment can be life-changing for Medicare beneficiaries, but coverage rules can be tricky. By helping your clients understand what Medicare covers, where to get equipment, and how to keep costs low, you can build trust and ensure they get the care they need without unexpected bills.