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Durable Medical Equipment & Medicare
Medicare Plans

Durable Medical Equipment & Medicare

by Jagger Esch
written by Jagger Esch

Many baby boomers rely on Durable Medical Equipment (DME) supplies for their daily activities. Medicare covers medically necessary supplies such as a wheelchair, CPAP machine, or oxygen tank.

So, if you’re wondering about Medicare coverage on your Durable Medical Equipment; ask yourself this; is this medically necessary and is my doctor going to write a prescription for this?

If you can answer yes, then coverage will be likely.

Will My Medicare Coverage Pay for Durable Medical Equipment?

Durable medical equipment is covered under Medicare Part B. The yearly Part B deductible is applicable and then Medicare pays an 80% coinsurance.

That means the Medicare Beneficiary is responsible for the remaining 20%.

If you’ve purchased secondary coverage through a private insurance company, they may pay the remaining 20% of the equipment costs.

Of course, that is provided you have met the Medicare requirements; like paying any applicable deductibles or premiums.

How Do I Get Medicare To Cover My Durable Medical Equipment?

Medicare requires standard information to be included with all prescriptions for durable medical equipment.

Typically, a face to face office note detailing medical necessity and a prescription.

Occasionally, Medicare may require additional testing or documentation. The DME provider should be able to guide Medicare Beneficiaries through the process.

You can expect equipment to be covered if it provides a therapeutic benefit for a condition or illness and will be used in the home.

Keep in mind that Medicare will cover the base model, any upgrades will be billed to the Medicare Beneficiary.

What If I need Durable Medical Equipment To Be Discharged From The Hospital?

When being sent home from the hospital, most people need a few supplies to make the transition smoother.

The most common prescribed items at the time of hospital discharge are hospital beds, wheelchairs, and bedside commodes.

The items that are necessary for Medicare Beneficiaries to continue recovery in the comfort of their own home, are typically covered.

These items will be covered by your Medicare Part B when the prescription is submitted along with the provider’s progress note detailing your condition and the medical necessity of the equipment.

Depending on the length of need, Medicare may rent or buy the equipment being ordered.

What If I Can’t Get Around My Home?

In some cases, a Medicare Beneficiary may have a long-term need for mobility. This could be due to a disability that is classified as temporary or permanent.

In either event, Medicare will cover a Power Mobility Device (PMD) provided specific criteria have been met.

For example, Medicare will require a face to face office note detailing the disability along with the doctor’s recommendation the patient will benefit from the device.

Provided the PMD is primarily used in the home, it will be considered a covered expense. Just to be clear, the Power Mobility Device can used outside the home.

Other items that improve mobility are:

 

There are numerous types of walkers and your practitioner will be able to assist you in determining which one would best meet your needs.

What If I Have A Need for Supplemental Oxygen, A Nebulizer or A Ventilator?

These items are all considered durable medical equipment and are covered under your Medicare Part B coverage.

As you know, anything considered a covered expense by Medicare will be considered payable by your Medicare Supplement Plan.

Oxygen is covered when the doctor details in the face to face office note the specific reason for supplemental oxygen. Oxygen is prescribed for persons with conditions such as COPD, also known as emphysema.

Nebulizers are used to atomize liquid medicine so the beneficiary can inhale a mist that will help open the alveoli, or air sacs. Nebulizers are commonly used by persons with asthma and infants.

Ventilators come in many forms and offer different treatment options. Medicare Part B will require a prescription, a face to face office note from the doctor detailing the condition, and the reason this DME is being ordered.

Ventilators can be either invasive or noninvasive.

  • An invasive ventilator does require an endotracheal tube which is inserted either through the nose or mouth.
  • A noninvasive ventilator requires only a mask.

 

Both types of ventilation therapy provide a volume and pressure to assist the user and provide support breathing.

What Is the Most Common Durable Medical Equipment Ordered?

Diabetic equipment is the most common equipment prescribed under Medicare Part B. Monitors and strips are covered.

Prosthetics and orthotic equipment that supports the lumbar or cervical spine are frequently prescribed. Personal care items such as bath chairs and dressing aids are also commonly prescribed.

What About My Sleep Apnea?

Medicare Part B does provide coverage for machines that correct obstructive sleep apnea.

These items are called CPAP and BiPAP machine. Depending on the type of sleep apnea, a doctor would allow the machine to correct the Medicare Beneficiaries condition.

Diagnosing sleep apnea is a quick process, but most people don’t know what symptoms should be cause for concern.

Sleep apnea is caused by either a physiological condition where the weight of the neck closes making the person stop breathing or breathe very slow, or a condition where the brain forgets to breathe.

Both are cause for concern because they put added strain on your heart and brain.

Signs to report to your doctor are snoring, insomnia, morning headaches or persistent daytime sleepiness.

What About the Monthly Supplies I Need for Upkeep?

Recurring supply needs are covered by your Medicare Part B coverage. Your DME company will be able to advise the frequency with which you can replace any durable medical equipment supplies.

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Health Insurance

Industry Experts Explain What Medicare Actually Covers

by Jagger Esch
written by Jagger Esch

Industry Experts Weigh in on Medical Services that Beneficiaries thought Medicare Paid for that Don’t

New Medicare beneficiaries tend to assume they’re fully covered by Original Medicare benefits. Unaware of the gaps in coverage, they end up finding out the hard way when they receive a medical bill in the mail. Industry Experts Explain What Medicare Actually Covers
Medicare Parts A & B only covers 80% of your medical costs. It has no out of pocket maximum and no prescription drug coverage. If you, or someone you know, only has Original Medicare, then this article pertains to you. Below, you’ll learn from industry experts as they explain what Medicare covers.

Medicare Does Not Cover it all

“We hear from many people who assume that long term care is covered by Medicare. Most are caught by surprise by that fact that Medicare does not cover long term care, only short-term rehab. This usually comes up when a loved one is no longer able to return home after a hospital stay and the shocking reality of paying privately for a care option is upon them. Another area we hear about Medicare not covering is scooters and walk-in tubs. These items are rarely covered by Medicare and once again, people are surprised by this harsh reality.” Amie Clark – Co-Founder of TheSeniorlist.com

  • Medicare does not cover Long-term care or support for your personal care needs. Most long-term care is not medical care, it is help with activities of daily living or personal tasks of everyday life. Medicare does suggest visiting LongTermCare.gov for information and resources to help you plan your long-term care needs. Medicare does cover care in a long-term care hospital, skilled nursing care in a skilled nursing facility, eligible home health services, hospice and respite care. Medicare will help cover durable medical equipment (DME) like scooters, walkers and wheelchairs if you have a medical need and qualify.

“People often assume that long term care, such as that provided by a nursing home, or a home health aide, is covered by Medicare. Unfortunately, that is not the case. Medicare will only pay for some short-term services after a hospitalization. Long term care can become a massive financial burden for much of the elderly population in the United States.” – Rebecca Gilbert, MD, PhD, APDA Vice President, Chief Scientific Officer.

  • Long term care not being covered can be a burden on beneficiaries and their families. I would recommend getting long-term care insurance before it is needed or too late. Many people are uninsured or underinsured, talking to an Insurance Agent to get questions answered and find the right plan for you is the best thing you can do.

“Patients and physicians are frequently confused about personal care services covered under Medicare benefits. They do not understand the difference between skilled and non-skilled home care services. For example, Medicare benefits cover a home health CNA when there is a skilled need and the patient meets home health criteria, including homebound status. Receiving this home health CNA service is temporary and can only be offered while nursing and/or therapy services are being provided, and at a low frequency (e.g. 1-2 visits per week). Non-skilled personal care services are not covered by insurance at this time and are paid privately or through special waivers. There is no time limit or guidelines as to who can receive personal care services since they are paid privately. Furthermore, DME supplies, such as transfer benches, adaptive feeding equipment and braces, are thought to be covered by Medicare, but are not. This is needed for safety in the home and should be covered to reduce further decline.” Sarah Deal – Interim Healthcare Inc

  • Having affordable DME supplies is vital for the elderly and disabled. While there are some DME supplies covered by Medicare, there are strict standards and both the doctor and the DME supplier need to accept Medicare assignment.

“There are several medical services that are not covered by Medicare that can cause a problem for seniors and their families. Many people have the preconceived misconception that Medicare pays for everything. On the contrary, there are Medicare deductibles, coinsurance and copays that has spawned a whole industry of supplemental plans to fill in the Medicare “gaps”. One of the areas that is not covered by Medicare is long-term care. We see this as a surprise to people on Medicare and their families because it is an area of care that so many seniors rely on later in life. However, Medicare itself does not cover nursing homes or custodial care. Now, there are insurance plans that you can purchase to cover that type of care, but these would, ideally, need to be purchased well before those benefits are needed. Another medical service that is not covered by “original” Medicare is prescription drugs. Prescription drug coverage for Medicare beneficiaries is provided through Medicare Part D. This is always a separate plan, sold through a private company, and it must be signed up for separately (you are not automatically enrolled in prescription drug coverage in most situations). Also, if you delay enrollment into prescription drug Part D coverage, you may face higher premiums due to Medicare’s Part D late enrollment penalty. Other medical care that is non-covered by Medicare are services for routine hearing, vision and dental care. There are some related aspects of these services that are covered, such as cataract surgery for example. But overall, routine care is not covered for hearing, vision or dental – this includes hearing aids, eyeglasses, and fillings, extractions, crowns, etc. You can purchase insurance to cover these things, but Medicare itself does not cover them.” Garrett Ball – Medicare Specialist at Senior.com

  • Medicare is not the most comprehensive coverage available. It does not cover many services. It is important for the Medicare beneficiary to purchase additional coverage. Some plans will include routine hearing, vision, and dental care. Part D Prescriptions Drug plans will need to be purchased through a private insurance company and you can be penalized if you are not enrolled in one when your part B goes into effect. Medicare is not the only insurance you want when something goes wrong with your health, you need to purchase additional coverage.

What you Can do to Prevent being Underinsured

Medicare does not cover everything; especially not long-term (custodial) care, routine dental, vision, hearing or prescription drugs. Working with an Insurance Agent or Counselor will help you get the coverage you need so you will be properly insured. Choose a plan that allows you to have the most consistent and reliable coverage year after year.

Looking for affordable DME products? Senior.com is a leader in the industry with affordable pricing and great customer service.
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What Medical Equipment is Covered by Medicare?
Medicare Plans

What Medical Equipment is Covered by Medicare?

by Garrett Ball
written by Garrett Ball

 
As you age, certain medical equipment may be necessary. If you use durable medical equipment (DME) and/or medical supplies which assist you in your daily functions, those items may be covered by Medicare Part B. Be aware that Medicare covers the basic model of that equipment. If you want to add on expensive upgrades, you typically will have to pay for any extra charges. What Medical Equipment is Covered by Medicare?

What Durable Medical Equipment (DME) is Covered by Medicare?

Some DME items must be purchased and other items can be rented. Generally, after 13 months of renting equipment, you will be able to own it. However, although oxygen equipment is always rented, you cannot purchase it. See below for a list of DME equipment and supplies that are covered when medically necessary:

  • Air-fluidized beds and other support surfaces (for rental use only)
  • Blood sugar monitors
  • Blood sugar (glucose) test strips
  • Canes (except white canes for the blind)
  • Commode chairs
  • Continuous passive motion (CPM) machine
  • Crutches
  • Hospital beds
  • Incontinence products
  • Infusion pumps and supplies (if necessary to administer certain drugs)
  • Manual wheelchairs and power mobility devices
  • Nebulizers and nebulizer medications
  • Oxygen equipment and accessories
  • Patient lifts
  • Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
  • Suction pumps
  • Traction equipment
  • Walkers

What Durable Medical Equipment (DME) is NOT Covered by Medicare?

  • Medicare will not pay for durable medical equipment which is used outside of the home. If you do not need it for assistance at home, then it will not be covered. An example would be a motorized scooter for use outside the home only, given that you can get around your house without it
  • Items only intended for ease or comfort, i.e. stairway elevators, grab bars, air conditioners, bathtubs and toilet seats
  • Any modifications made to your home, i.e. ramps, widened doors, to facilitate wheelchair access
  • Equipment not suitable for home use, i.e. paraffin bath units and oscillating beds
  • Disposable items or items not used with equipment, incontinence pads, catheters, surgical face masks, or compression leggings. Note: If you get home health care, Medicare will pay for some of these items as part of your benefit, such as intravenous supplies, gauze, and catheters.

There are criteria that the DME must meet prior to being approved by Medicare, as follows:

  • It must be “durable”, resilient and long-lasting
  • It must be medically necessary and prescribed by your physician or other health care provider to be used at home. Note: It cannot be more than 6 months before the date of the order
  • It must not be used by someone else who isn’t sick or injured
  • It must be strong enough to withstand repeated use and last for at least 3 years.

Special Requirements for Certain DME Items

There are special rules for items that are more expensive, some examples are below:
Wheelchairs: Your healthcare provider’s order should indicate the following:

  • that it is difficult for you to manage at home with just a cane or a walker. You must also be having difficulties in your daily functioning as getting dressed or bathing.
  • the date of your office visit
  • that you can use the wheelchair safely.

Power scooters:

  • The scooter must be ordered within 45 days of your healthcare provider’s prescription. His order will have to stipulate that you have the same problems listed above for getting a wheelchair. However, the order must also stipulate that you can’t use a manual wheelchair but could safely use a powered one.

Please note that some states have additional rules and required forms for wheelchairs and scooters. Check with your doctor to be sure you follow those rules.

How Do You Get Durable Medical Equipment (DME) Covered by Medicare?

You must get your DME from a Medicare-approved supplier. Both Original Medicare and Medicare Advantage plans have approved lists of suppliers. To find them in your area, go to the supplier directory at www.medicare.gov/supplierdirectory/search.html. You will need to use suppliers that are “approved” by your plan – either original Medicare or Medicare Advantage.
Medigap plans will also cover DME if Medicare approves it. It will be covered as a normal Part B charge – the Medicare Part B deductible will apply if you have a Medigap plan that does not cover the deductible. But after that Medicare and the Medigap plan should cover your costs in full for covered equipment.

DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

Competitive Bidding Program:

After suppliers submit their bids to provide certain DME and supplies in competitive bidding areas, an amount is agreed upon by Medicare for payment of each item. Medicare contract suppliers are selected from the suppliers with winning bids.

  • This program is cost-effective. Its primary goal is to save Medicare and its beneficiaries money.
  • It operates in certain zip codes in the Northeast, South, Midwest and West.
  • It ensures that you get top quality products from Medicare-approved suppliers.
  • It helps to minimize fraudulent and abusive practices in the Medicare system.

If you have questions about what Medicare will or will not cover, it is best to contact Medicare directly before agreeing to pursue purchasing or renting any equipment. You can find some information on Medicare’s website or by calling them at 1-800-MEDICARE.
Senior.com does not accept Medicare. However, our customers regularly get prior approval from Medicare for DME products and then submit the receipt with proper paperwork for reimbursement to Medicare.
 

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