In this month's article, I will discuss Medicare's coverage of durable medical equipment, which is called DME for short. It is equipment that helps you complete daily activities. This category is also sometimes labeled more inclusively as DMEPOS for durable medical equipment, prosthetics, orthotics, and supplies.
Medical equipment to help you daily
Durable medical equipment (DME) are items that help you complete your daily activities including a variety of items, such as walkers, wheelchairs, hospital beds, and portable oxygen tanks. Medicare usually covers DME if the equipment:
-Is durable, meaning it is able to withstand repeated use.
-Serves a medical purpose.
-Is appropriate for use in the home, although you can also use it outside the home.
And is likely to last for three years or more.
To be covered by Part B, DME must be prescribed by your treating practitioner, may require a face-to-face office visit within six months of prescription, and obtained from a Medicare-approved supplier. Avoid suppliers who do not have a contract with Medicare, as you will be responsible for the entire cost of the equipment.
Be aware that many suppliers are Medicare-approved but do not take assignment. These suppliers may charge you more than Medicare's approved amount for the cost of services. Medicare will still only pay 80% of its approved amount for services, so you will be responsible for any additional costs.
Under the durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) category, Medicare Part B also covers:
-Prosthetic devices that replace all or part of an internal bodily organ;
-Prosthetics, like artificial legs, arms, and eyes;
-Orthotics, like rigid or semi-rigid leg, arm, back, and neck braces; or
-Certain medical supplies.
Medicare Part B also covers certain prescription medications and supplies that you use with your DME, even if they are disposable or can only be used once. For example, Medicare covers medications used with nebulizers, or lancets and test strips used with diabetes self-testing equipment.
Items not covered by Medicare
Certain kinds of durable medical equipment (DME) and supplies that Medicare does not cover include the following:
Equipment mainly intended to help you outside the home. For example, if you can walk on your own for short distances- enough to get around your house -Medicare does not cover a motorized scooter that you only need outside the home.
Most items intended mainly to make things more convenient or comfortable. This includes stairway elevators, grab bars, air conditioners, and bathtub and toilet seats.
Items that get thrown away after use or that are not used with equipment. For example, Medicare does not cover incontinence pads, catheters, surgical facemasks, or compression leggings. However, if you receive home health care, Medicare pays for some disposable supplies -including intravenous supplies, gauze, and catheters-as part of your home health care benefit. Note: Catheters may be covered as prosthetics if you have a permanent condition.
Modifications to your home, such as ramps or widened doors for improving wheelchair access.
Equipment that is not suitable for use in the home. This includes some types of DME used in hospitals or skilled nursing facilities (SNFs), like paraffin bath units and oscillating beds.
Keep in mind that Medicaid may cover some forms of equipment that Medicare will not cover.
Obtaining DME with both Medicare and Medicaid
There are Alaskans who have both Medicare and Medicaid (also known as DenaliCare). If this is the case, remember that Medicare coverage pays first; Medicaid is known as the "payer of last resort." When obtaining any DMEPOS, Part B is billed by the approved supplier before Medicaid is billed. Failure to do so may mean that Medicaid will deny payment, resulting in out-of-pocket costs to receive supplies or equipment. If you have questions, contact your health care provider, your DMEPOS supplier or find a Medicare-enrolled supplier (through the Medicare.gov website).
To discuss any concern relating to obtaining DME through Medicare, or to ask any questions regarding your specific situation, please contact the State of Alaska Medicare Information Office at (800) 478-6065 or (907) 269-3680; our office is also known as the State Health Insurance Assistance Program (SHIP), the Senior Medicare Patrol (SMP), and the Medicare Improvements for Patients and Providers Act (MIPPA) program. If you are part of an agency or organization that assists Seniors with medical resources, consider networking with the Medicare Information Office. Call us to inquire about our Ambassador program.
Sean McPhilamy is a volunteer and Certified Medicare Counselor for the Alaska Medicare Information Office.
