Medicare and DME

In addition to covering a wide range of services, Medicare also covers certain medical devices, items and supplies often referred to as durable medical equipment (DME).

The Centers for Medicare & Medicaid Services (CMS) defines durable medical equipment as special medical equipment, such as wheelchairs or hospital beds, that are prescribed by your medical provider for use in your home.

Use this guide to learn more about durable medical equipment, including a list of some of the DME that Medicare covers and the estimated costs you can expect to pay.

Woman using a walker outside

What durable medical equipment does Medicare cover?

Medicare covers a range of items, supplies and equipment as durable medical equipment. The list of DME that is covered by Medicare includes (but is not limited to):

The classification of DME extends to DMEPOS, or durable medical equipment, prosthetics, orthotics and supplies. Items in this classification include prosthetics such as artificial limbs or other body parts, along with things like braces and wound dressings.

When does Medicare pay for DME?

In order for durable medical equipment to be covered by Medicare, the item in question must be:

  • Durable, meaning it can withstand repeated use
  • Used for a medical reason
  • Not typically used by anyone who is not sick or injured
  • Used in the home
  • Expected to last for at least three years of use

How does Medicare cover DME?

Durable medical equipment is covered by Medicare Part B (medical insurance). Once you meet your Part B deductible ($185 per year in 2019), you are typically required to pay a 20 percent coinsurance for the Medicare-approved cost for your qualified DME.

The following criteria must be met before Medicare will pay for your DME:

  • The equipment must be considered medically necessary and prescribed for use in the home by a primary care physician. Most items will require your doctor to submit a Certificate of Medical Necessity (CMN).

  • Your doctor must be approved by and accept Medicare. If your doctor accepts Medicare but does not accept Medicare assignment, they may be allowed to charge more than the Medicare-approved amount for your DME.

  • The DME supplier must also be enrolled in Medicare.

Depending on the type of durable medical equipment, you may have to purchase or rent the item.

What is the Medicare Competitive Bidding Program?

Depending on where you live, the cost of your DME may be affected by the Competitive Bidding Program.

Under the program, DME suppliers submit a bid to Medicare to supply certain products to Medicare beneficiaries. Medicare then sets the amount it will pay for each item based on these bids.

The federal Medicare website provides a list of areas that utilize competitive bidding, as well as the types of DME that are affected.

Where can I find Medicare durable medical equipment?

Durable medical equipment can typically be obtained from three different types of providers, and each may carry a different cost for the same item.

Be sure to check with your doctor and your DME supplier to find out how much your equipment may cost.

  • Participating providers
    A participating provider accepts the Medicare-approved amount as full payment for their equipment. The Medicare-approved amount is the amount of money that Medicare has determined it will pay for particular services and items.

  • Non-participating providers
    A non-participating provider accepts Medicare patients, but does not accept the Medicare-approved amount as full payment.

    Non-participating providers reserve the right to charge you up to 15 percent more than the Medicare-approved amount for their durable medical equipment, which becomes your responsibility to pay.

    This extra charge is known as a Medicare Part B excess charge.

  • Opt-out providers
    An opt-out provider has elected to opt out of Medicare entirely and does not accept Medicare insurance as payment.

    Medicare beneficiaries may still receive care from these providers but will not be able to pay for any services or items using their Medicare coverage. 

DME and Medicare Supplement Insurance

Medicare Supplement Insurance plans, or Medigap, provide coverage for many of the out-of-pocket costs that Medicare Part A and Part B don't cover.

Some Medigap plans can help cover some of the out-of-pocket costs associated with durable medical equipment. 

DME costs that may be covered by certain Medigap plans can include:

  • Annual Part B deductible
    Before Part B will provide any coverage for DME, you must first meet an annual deductible of $185 in 2019.

    In other words, you must pay $185 out of your own pocket for covered medical equipment items before your Part B coverage takes effect.

    Medigap Plan C and Plan F both cover the Part B deductible.

  • Part B Coinsurance
    After you meet your Part B deductible, you will typically be charged 20 percent of the Medicare-approved amount for a DME item.

    For example, if your medical equipment carries a Medicare-approved amount of $200 and you've already met your Part B deductible, you will be responsible for paying $40 (20 percent of $200).

    Each type of standardized Medigap plan provides at least some coverage for Part B coinsurance costs.

  • Part B excess charges
    As mentioned above, when an item of DME is obtained from a non-participating provider, you may be charged up to 15 percent more than the Medicare-approved amount for your item.

    Medigap Plan F and Plan G each provide full coverage for Part B excess charges. 

Learn more about how Medicare Supplement Insurance can help cover durable medical equipment.

DME and Medicare Advantage plans

By law, Medicare Advantage plans are required to provide at least the same benefits as Medicare Part A and Part B (known together as Original Medicare).

This means that Medicare Advantage plans provide the same coverage for qualified DME as Original Medicare.

Many Medicare Advantage plans also offer a number of benefits not covered by Original Medicare. This includes providing coverage for certain items that can help make it easier for people to age in place at home, some of which are not currently classified as DME and therefore not covered by Original Medicare.

In 2019, some Medicare Advantage plans may now provide coverage for equipment like bathroom grab bars, wheelchair ramps and air conditioners for people with asthma.

Ask a licensed insurance agent what additional benefits may be covered by the plans you are considering.

Find a Medicare Advantage plan that covers the DME you need

Are you looking for Medicare coverage for your approved DME? Do you want to find a plan that may also cover additional medical equipment that isn’t covered by Original Medicare? You may be able to find a Medicare Advantage plan that offers the benefits you need.

Call to speak with a licensed insurance agent who can help you compare Medicare Advantage plans that are available where you live.

 

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Or call TTY Users: 711 24/7 to speak with a licensed insurance agent.