Original Medicare DME Coverage: What You Need to Know

Whether you need a wheelchair to maintain your mobility, a CPAP machine to manage sleep apnea, or diabetic supplies to keep your blood sugar levels in check, knowing what’s covered and how to access these essential items is important.

We’ll break down everything you need to know about Original Medicare DME coverage, from the types of equipment included to the eligibility requirements and explain how Healthpilot can help you out.

What Is Durable Medical Equipment (DME) Durable Medical Equipment (DME) are medical devices that are designed to be used repeatedly, serve a medical purpose, and are suitable for use in the home.

These items are crucial for patients who require assistance with their medical conditions on a long-term basis.

DME encompasses a wide range of equipment that supports patients in their daily activities, promotes safety, and enhances their quality of life.

Key Characteristics of DME:

Durability: The equipment must withstand repeated use and it is generally expected to last at least three years. Medical Purpose: The primary use of the equipment must be to serve a medical function, rather than for convenience or comfort. Home usage : DME is typically used in the home setting, although it can also be utilized in facilities like nursing homes or assisted living centers.

A wheelchair can be covered by Medicare with a doctor's prescription, helping to improve mobility and independence

List of Durable Medical Equipment Covered by Original Medicare

Medicare Part B covers a wide range of Durable Medical Equipment (DME) that is deemed medically necessary for use in your home. Here is a comprehensive list of commonly covered DME items:

Mobility Aids Wheelchairs (manual and power-operated) Scooters (power-operated vehicles) Walkers and rollators Canes and crutches Hospital Beds Standard hospital beds Adjustable beds Bedside rails Oxygen Equipment and Accessories Oxygen concentrators Portable oxygen tanks Oxygen tubing and masks CPAP (Continuous Positive Airway Pressure) devices Diabetic Supplies Blood glucose monitors Test strips Lancet devices and lancets Insulin pumps and supplies Respiratory Equipment Nebulizers Ventilators Continuous Positive Airway Pressure (CPAP) devices Bi-level Positive Airway Pressure (BiPAP) devices Home Infusion Therapy Equipment Infusion pumps Intravenous poles Supplies for infusion therapy (tubing, needles) Patient Lifts Hydraulic lifts Electric lifts Transfer benches Commode Chairs Standard bedside commodes Drop-arm commodes Shower commode chairs Prosthetic and Orthotic Devices Artificial limbs (prosthetics) Orthotic braces and supports Diabetic shoes and inserts Speech Generating Devices Communication devices for individuals with speech impairments Enteral Feeding Equipment and Supplies Feeding pumps Feeding tubes Nutritional supplements and solutions Wound Care Supplies Negative pressure wound therapy (NPWT) pumps Dressings and bandages for chronic wounds Understanding Original Medicare's Eligibility Requirements for DME Medicare provides coverage for Durable Medical Equipment (DME) under Part B, but there are specific eligibility requirements and guidelines you need to meet to ensure your equipment is covered.

To be eligible for DME coverage under Medicare, the following conditions must be met:

Medicare Part B Enrollment: You must be enrolled in Medicare Part B (Medical Insurance). This part of Medicare covers outpatient care, preventive services, and DME. Medical necessity: The DME must be considered medically necessary. This means it is needed for the diagnosis or treatment of your medical condition and must be prescribed by your doctor. Doctor’s prescription: Your doctor or healthcare provider must write a prescription that includes your diagnosis, the type of equipment needed, and how it will help your condition. Home use: The equipment must be suitable for use in your home. Medicare typically covers DME that helps you perform everyday activities at home. How to Obtain DME Through Medicare Obtaining Durable Medical Equipment (DME) through Medicare Part B involves several steps, from getting a prescription to working with approved suppliers.

Here’s how to obtain a DME through Medicare Part B:

Consult with Your Healthcare Provider Begin by scheduling an appointment with your healthcare provider to discuss your medical condition and the need for DME. Your doctor will evaluate your health and determine if DME is medically necessary.

If your doctor determines that you need DME, they will write a prescription or order specifying the type of equipment required and the medical justification for it.

Face-to-Face Examination (if required) For certain types of DME, such as power wheelchairs and scooters, Medicare requires a face-to-face examination between you and your prescribing doctor. This examination must occur within six months before the prescription date.

Detailed Written Order Your healthcare provider must provide a detailed written order that includes your diagnosis, the type of DME prescribed, and the medical necessity for the equipment. This order should also include any additional supporting documentation, such as test results or medical records.

Choose a Medicare-Approved Supplier Use the Medicare Supplier Directory to find Medicare-approved suppliers in your area. These suppliers must accept Medicare assignment, meaning they agree to accept the Medicare-approved amount as full payment.

Compare suppliers based on location, availability of equipment, and customer reviews to find the best option for your needs.

Submit Your Prescription and Documentation Provide the chosen supplier with your prescription and any additional documentation. The supplier will use this information to verify your eligibility and submit a claim to Medicare on your behalf.

For certain high-cost items, Original Medicare may require prior authorization. Your supplier will inform you if this step is necessary and will handle the submission process to Medicare for approval.

Receive and Use Your DME Once Medicare Part B approves the claim, the supplier will deliver the equipment to your home. They may also provide instructions on how to use and maintain the equipment properly.

Some suppliers offer training or instructional sessions to ensure you understand how to use the equipment safely and effectively.

Understand Your Costs Medicare Part B typically covers 80% of the Medicare-approved amount for DME. You are responsible for the remaining 20%, as well as any applicable Part B deductible.

If you have supplemental insurance (Medigap), it may cover the remaining costs. Otherwise, you will need to pay the 20% coinsurance out-of-pocket.

Selecting a Medicare-Approved Supplier Choosing the right Medicare-approved supplier for your Durable Medical Equipment (DME) is a critical step in ensuring you receive high-quality, reliable equipment and optimal service.

Only Medicare-approved suppliers can bill Medicare directly and accept the Medicare-approved amount as full payment. This ensures that you receive the maximum coverage and minimize out-of-pocket expenses.

Medicare-approved suppliers must meet specific standards and regulations, ensuring they provide high-quality equipment and services. Suppliers who accept assignments agree to the Medicare-approved amount, protecting you from being overcharged.

Medicare.gov provides an online Supplier Directory to help beneficiaries find approved suppliers. You can search by location, type of equipment, and supplier name. Visit the Medicare Supplier Directory to start your search.

Costs and Reimbursement for DME Under Medicare Understanding the costs and reimbursement processes for Durable Medical Equipment (DME) under Original Medicare is essential for beneficiaries to manage their healthcare expenses effectively. Here’s a comprehensive overview of what you need to know about costs and reimbursement for DME.

Medicare Coverage for DME Medicare Part B: Medicare Part B covers medically necessary DME prescribed by a healthcare provider for use in the home. Part B typically covers 80% of the Medicare-approved amount for the equipment, leaving the beneficiary responsible for the remaining 20% and any applicable Part B deductible. Medicare-Approved Amount The Medicare-approved amount is the maximum amount Medicare Part B will pay for a covered service or item. This is usually less than the actual charge.

The approved amount is determined by Medicare and is based on the type of equipment and geographical location.

Deductible: Beneficiaries must meet the annual Medicare Part B deductible before Medicare begins to pay its share. As of 2024, the Part B deductible is $226, but this amount may change yearly. Coinsurance: After meeting the deductible, beneficiaries are responsible for 20% of the Medicare-approved amount for the DME. Example of DME Cost Calculation: If the Medicare-approved amount for a wheelchair is $800:

Medicare pays 80%: $640 Beneficiary pays 20% coinsurance: $160 If the Part B deductible hasn’t been met, the beneficiary must pay up to the deductible amount before coinsurance applies.

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