Durable Medical Equipment (DME) consists of medical apparatuses prescribed by a physician for use by beneficiaries in their homes to treat an illness or injury. Medicare provides coverage for this equipment, but only when specific criteria are met for both the item and the administrative process. Understanding these rules helps minimize unexpected expenses.
Defining Durable Medical Equipment
The classification of equipment as DME is governed by specific federal regulations, ensuring coverage is reserved for medical necessities. To qualify, the item must be durable, meaning it can withstand repeated use and is generally expected to have a minimum lifespan of at least three years.
The equipment must also be primarily used for a medical purpose, such as a wheelchair or an oxygen concentrator. This excludes items generally useful even without illness or injury, such as personal comfort items or standard air conditioners. Furthermore, the item must be appropriate for use in the patient’s home, which includes a nursing facility that is not a hospital or a skilled nursing facility.
Examples of equipment that typically qualify as DME include hospital beds, power wheelchairs, patient lifts, and nebulizers. Conversely, disposable medical supplies (like surgical face masks or incontinence pads) or items meant for convenience (like a ramp installation) generally do not meet the criteria for DME coverage.
Medicare Coverage Requirements
Coverage for Durable Medical Equipment is primarily handled under Medicare Part B. For Medicare to cover the cost, the equipment must be certified as medically necessary by a treating practitioner (such as a physician, physician assistant, or nurse practitioner). This certification requires a written order or prescription documenting the beneficiary’s need for the specific item.
The process may involve a choice between renting or purchasing the equipment, depending on the item type and the expected duration of need. For many high-cost items, Medicare often mandates a rental period, such as 13 months, after which the equipment ownership may transfer to the beneficiary. However, certain equipment, like oxygen tanks and accessories, is typically limited to a rental-only basis for a specified period.
Patient Costs and Approved Suppliers
Beneficiaries are responsible for a portion of the cost of their DME, even after the Part B deductible has been met. The standard cost-sharing model requires the beneficiary to pay a 20% coinsurance of the Medicare-approved amount for the equipment.
Equipment must be obtained from a Medicare-enrolled and accredited supplier to ensure coverage. If a supplier does not participate in Medicare or accept “assignment” of the claim, they may charge the beneficiary more than the Medicare-approved amount. The beneficiary is then responsible for the 20% coinsurance plus any charges exceeding the amount Medicare allows.