Medicare coverage for durable medical equipment
September 1, 2018
Perhaps you have heard advertising that you can purchase back braces, knee braces, and other items with little or no cost to you and that Medicare will pay for them. Let’s get to the truth of these advertisements.
First of all – what is Durable Medical Equipment (DME)?
DME is defined as equipment that is durable, reusable and is needed to treat an illness or an injury, or to improve the functioning of a malformed body part. These are items that are designed to withstand repeated use. Medicare generally expects many DME items to last for three years or more.
The equipment must serve a medical purpose – not just for a patient’s convenience. And the equipment is designated for home use, although you may be able to use the equipment outside the home.
Some examples of DME items: Walkers, wheelchairs, hospital beds, power scooters, portable oxygen equipment and diabetic testing supplies.
Medicare covers prosthetics, orthotics and supplies under the Durable Medical Equipment Prosthetics, Orthotics & Supplies (DMEPOS) category. Examples of these would be prosthetic devices that replace all or part of an internal organ or prosthetic devices that replace an external body part like artificial legs, arms and eyes. Medicare covers orthotics like braces for arms, backs, legs and necks. Medicare will also cover supplies and medications that are needed to use with your DME even though they are disposable and may be used only once. An example would be the medications used to keep an IV port site open or diabetic testing supplies like lancets and testing strips that are used with a glucometer.
There are equipment and supplies that Medicare does not cover. Equipment generally used to assist you outside your home, items intended for convenience or comfort are usually not covered. Also not covered are items intended for disposal after one use or are not used with equipment. Medicare will not pay for modifications to your home or equipment that is not suitable for use in the home. Some examples of things Medicare will not cover are: Incontinence supplies, wheelchair ramps, surgical facemasks, air conditioners, or home modifications such as widening of doorways. They also will not pay for a wheelchair or scooter that is intended for outside use.
If you are an inpatient in a hospital or skilled nursing facility, Medicare’s payment for DME will be included in the payment Medicare makes to the facility. As an outpatient, to get DME covered by Medicare you must have a face to face meeting with a doctor and he must provide an order, prescription or certificate that states the visit has occurred and expresses your need for the DME item for a medical condition or injury and the equipment is for home use. This visit must take place within six months prior to the prescription being written. After receiving the right documentation, it must be submitted to the correct DME supplier.
Medicare DME suppliers are not all the same. The type of supplier you will use depends on both where you live and the type of DME you need.
Original Medicare only covers DME from a select group of providers in what Medicare calls “Competitive Bidding Areas”. These are known as contract suppliers. In Alaska, the only items that are designated as having to use competitive bidding are diabetic testing supplies. All other DME items can be accessed by any Medicare DME supplier. If you want to use a supplier that is not a contract supplier, they must
notify you of their status prior to your purchase and have you sign an Advanced Beneficiary Notice. This document states that you understand that Medicare will not pay for this item and you are 100 percent responsible for the cost. If the supplier does not have you sign this document, you are not responsible for the cost.
A great way to locate a supplier either for mail order supplies or a local supplier is to use the search tool available at Medicare.gov. The search tool is located at the bottom of the Medicare.gov homepage. You identify what type of provider or supplier you are searching for by category, then provide your ZIP code and the specific type of provider and click on “search”. This tool will bring up a list of the providers in that area or that serve that area. This search tool also notifies you of the suppliers that take assignment. This means that the supplier accepts the Medicare payment as payment in full. Some providers can charge up to 15 percent above the Medicare-approved amount – this is known as a limiting charge. DME is not subject to a limiting charge so a provider who does not take assignment can charge you the difference between what Medicare pays and the price they are charging for the item.
Additionally, sometimes DME is rented, sometimes it is purchased. For instance, oxygen equipment rental, repairs and maintenance have special rules. Power wheelchairs and scooters have specific documentation that your doctor must provide. If you have questions about coverage for DME that you need, or if you think that you have been a victim of DME fraud, contact the State of Alaska Medicare Information Office at 1-800-478-6065.
Nila Morgan is a Certified Medicare Counselor who works at the Anchorage Senior Activity Center.