Do you or someone you know use an external insulin pump, wheelchair, CPAP machine, or oxygen tank? If so, you may know that certain equipment can be pricey and wonder how your insurance can help cover some of that cost. Many of these items are more commonly used by seniors; therefore, Medicare is the primary insurance. Understanding Medicare’s coverage with durable medical equipment (DME) will be helpful as you approach your Medicare eligibility. You will also want to consider supplemental plans, which you can learn more about at boomerbenefits.com/medicare-supplemental-insurance.
What is durable medical equipment?
DME can come in several forms, but the purpose is the same. It’s equipment that provides medical or therapeutic benefits to someone with specific health conditions.
Some examples of DME are:
- Nebulizers and the medicine used in them
- Infusion pumps and other supplies
- Back and knee braces
- Walkers and crutches
- Certain incontinence products
It’s important to know that Medicare has requirements when it comes to DME. Typically, Medicare will cover the basic models and those only provided by Medicare-approved suppliers.
How does Medicare cover DME?
DME generally falls under Medicare Part B, which helps cover outpatient medical services. What this means for you is the Part B deductible and coinsurance apply. Therefore, you will need to meet the $233 (in 2022) annual deductible first before Part B offers some coverage. Once that deductible is met for the year, Medicare covers 80% of the cost, and you are responsible for the remaining 20%. There is no cap to your costs with Original Medicare only.
How to get your DME
When you have an appointment with your doctor about DME, you will need to ensure you get a prescription for the specific equipment you need. Sometimes to get a prescription, you need to complete an additional visit, such as a sleep study for those with sleep apnea needing a new CPAP machine.
Once you have your prescription, you can take that to a Medicare-approved supplier and order your new DME.
However, remember that some equipment may have a restriction on how often you can get a new one. Each kind of equipment may have a different time limit, but often, you may not be able to get a new one with Medicare until you’ve had your current one for at least five years. You can discuss this further with the supplier or Medicare directly.
DME and Medicare Supplemental plans
If you pair your Original Medicare with a Medigap plan, then your Medigap plan must cover the remaining balance for approved services. When Medicare pays, your Medigap pays as well. However, that also means if Medicare doesn’t pay, then neither will your Medigap plan.
Now, let’s say you choose a Medicare Advantage plan instead of a Supplement plan. In that case, your Advantage plan handles your Original Medicare benefits. Although the Advantage plan must offer the same benefits as Part A and Part B, they can set different criteria or requirements. You also want to ensure your doctors and suppliers accept your plan. You can refer to your plan’s Summary of Benefits document to learn more about the DME services it covers and how much you are responsible for.
If you already have durable medical equipment before Medicare, it’s essential to learn about how Medicare covers DME before enrolling. You can prepare for the necessary steps you’ll need to take in case you need a new piece of equipment while on Medicare. It’s very possible your current equipment will need repairs or new accessories, so the more preparation you do, the better.