Understanding Insurance for Durable Medical Equipment

Updated on January 12, 2020

Caring for an aging or ailing loved one at home is difficult. Plus, understanding what insurance covers and what it doesn’t can make it even harder—especially when sorting out coverage for home care, equipment, medicines, and supplies. One area that is often confusing is coverage for equipment needed to provide at-home care. Patients, caregivers, and families may need help understanding insurance for durable medical equipment (DME).

What Qualifies as Durable Medical Equipment?

Private insurers may have different lists of what kind of equipment they’ll cover, but Medicare’s definition of durable medical equipment is a good place to start. Medicare defines “durable medical equipment” as equipment that is:

  • Durable (meant to last – withstands repeated use and likely to last three years)
  • Medically necessary (doctor prescribed)
  • Used for a medical reason
  • Not intended for someone who isn’t sick or injured
  • Used at home 

“Used in the home” can be tricky. If the device provides assistance primarily outside the home, and the patient can manage without it in their dwelling, Medicare won’t pay. Medicare also won’t pay if the prescribing healthcare provider doesn’t participate in Medicare (i.e. isn’t “enrolled”).  Further, insurance may not cover items that simply make life more convenient in the home, such as air conditioners or special toilet seats. 

In addition to getting a prescription from a physician that participates in Medicare, it’s also very important for patients and caregivers to check if the equipment supplier accepts “assignment” from Medicare. This means they will accept the amount Medicare pays as the full payment for the device. 

What Are Some Examples of DME?

The first criterion for DME is that it be durable or reusable. However, it’s important to note Medicare covers blood sugar test strips, which typically are not individually reusable. As such, it is important not to make assumptions and check if insurance will cover the equipment. Medicare covers commodes, CPAP devices, hospital beds, lifts, wheelchairs, and walkers, as well as https://www.fashionablecanes.com/canes-articles/will-medicare-insurance-pay-for-walking-cane.htmlcanes. But Medicare imposes limits on how much it will pay for these devices. So, while it’s fair to expect functionality, it may be unreasonable to demand luxury unless the patient is willing to pay out of pocket.  

Original Medicare Won’t Pay for Home Modifications

While a walk-in tub or a wheelchair ramp may seem absolutely necessary, Medicare will not pay for home modifications. This includes changes such as grab bars or widened doorways. Medicare also excludes assistive devices that may be convenient but are not medically necessary, such as large-button remote controls or video doorbells.  However, Medicare Advantage plans now have the discretion to cover home modifications and other supplemental benefits. These are plans purchased from private insurers who have contracted with Medicare and pledge to provide at least the same coverage as Parts A and B. Some advantage plans may even cost less than Medicare and provide greater coverage. When open enrollment comes around in the fall, comparison shopping may pay off for patients with chronic conditions who need care in the home. So be sure to do your homework when it comes to understanding insurance for durable medical equipment.

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