Durable medical equipment, also called DME for short, is equipment that helps you complete daily activities. This category is also sometimes called DMEPOS for durable medical equipment, prosthetics, orthotics, and supplies. This blog post will help you understand Medicare’s coverage of DME, DME suppliers, and who to contact for more assistance.
First, let’s understand what Medicare covers as durable medical equipment.
Medicare usually covers DME if the equipment:
Is durable, meaning it can 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.
Whether you have Original Medicare or a Medicare Advantage Plan, the types of Medicare-covered equipment should be the same. Examples of DME include:
Portable oxygen equipment
Medicare 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 medication used with nebulizers or lancets and test strips used with diabetes self-testing equipment. These are under the category of DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies), which also includes prosthetics and orthotics.
There are certain kinds of equipment and supplies that Medicare does not cover, such as equipment mainly intended to help you outside of the home or items that get thrown away after use or are not used with equipment. Medicare’s DME coverage additionally does not include most items intended mainly to make things more convenient or comfortable, modifications to your home, or equipment that is not suitable for use in the home. Examples of equipment that is not DME include surgical facemasks, wheelchair ramps, incontinence pads, and wheelchairs or scooters that are only intended for use outside the home.
If you’d like to learn more about Medicare’s coverage of DME, contact your local State Health Insurance Assistance Program (SHIP). The SHIPs have trusted and knowledgeable counselors who can provide you with individualized counseling around these topics. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).
So, how do you get your DME covered by Medicare?
DME must be prescribed by your primary care provider, or PCP. Your PCP must sign an order, prescription, or certificate. In this document, your PCP must state that:
You need the requested DME to help a medical condition or injury
The equipment is for home use
And that, if applicable, the required face-to-face visit occurred
Your face-to-face visit, when required, must take place no more than six months before the prescription is written. Your provider should know if Medicare requires a face-to-face visit for the item you need.
Once you have your PCP’s order or prescription, you must take it to the right supplier to get coverage. Do note that if you need coverage for a manual or power wheelchair or scooter, the process is different and may require your PCP to send a prior authorization request to Medicare.
Next, you will want to go to the right supplier to ensure that your DME is covered.
If you have a Medicare Advantage Plan, you must follow the plan’s rules for getting DME. Your plan may require that you receive approval from the plan before getting your DME, use a supplier in the plan’s network of suppliers, or use a preferred brand of DME. Contact your plan directly to learn more about its rules and to find in-network suppliers.
If you have Original Medicare, you should get your DME from a Medicare-approved supplier that takes assignment. Providers who take assignment cannot charge you more than 20% of Medicare’s approved amount for the cost of the DME. Be aware that many suppliers are Medicare-approved but do not take assignment. These suppliers may charge you more than 20% of Medicare’s approved amount. Medicare will still only pay 80% of its approved amount for the DME, so you will be responsible for any additional costs. You should also avoid suppliers who do not contract with Medicare, because Medicare will not pay for services you receive from these suppliers. This means you are responsible for the entire cost. Call your State Health Insurance Assistance Program (SHIP) for assistance finding Medicare-approved DME suppliers that take assignment. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to speak with a SHIP counselor.
Finally, remember the rules about Medicare’s coverage of DME and protect yourself from DME fraud.
Medicare will not cover DME unless your doctor has certified that you need it. Be aware of aggressive marketing that tries to offer you free equipment or persuade you to change DME suppliers. Before making a decision to change suppliers, speak with your doctor and your current supplier to see if there is a need for you to change. Be skeptical of offers that seem too good to be true, and do not give any personal information to someone who calls offering DME that you did not ask for. Regularly check your Medicare Summary Notices (MSNs) if you have Original Medicare, or your Explanations of Benefits (EOBs) if you have a Medicare Advantage Plan. If you see any suspicious charges or have any reason to believe your provider is inappropriately billing Medicare, call your provider to see if they have made a billing error. If you still suspect a health care provider of DME fraud, contact your Senior Medicare Patrol (SMP). You can contact your SMP by visiting www.smpresource.org or calling 877-808-2468.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for questions about your Medicare coverage and any problems that arise with it. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.)
Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).