DME is defined as an item that
Can withstand repeated use,
Primarily and customarily serves a medical purpose, and
Generally, isn’t useful to an individual in the absence of an injury or illness
Improves, restores, or maintains the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient’s function or condition
Maximizes the patient’s function consistent with their physiological or medical needs
Provides the medically appropriate level of performance and quality for the medical condition present
Isn’t otherwise excluded by the regulation and policy
also covers
* Medically necessary To be medically necessary means it is appropriate, reasonable, and adequate for your condition. customization or attachments to the DME to accommodate your medical disability, when your physician has prescribed the equipment as medically necessary and appropriate.
* Medically necessary covered accessories and attachments to a DME necessary to make the DME “serviceable” for a particular disability. For example, a car lift that is an accessory to a wheelchair.
* Repairs to equipment that you own when needed to make the item serviceable.
* Replacement of DME that you own when:
* There’s a change in your physical condition,
* There’s accidental damage to the DME,
* The DME is inoperative and can’t be repaired, or
* The U.S. Food and Drug Administration has declared the DME adulterated.
* Duplicate items (those that serve the same purpose, but may not be an exact duplicate, such as a portable oxygen concentrator as a backup for a stationary oxygen generator) that are essential to provide a fail-safe, in-home life-support system.
doesn’t cover
* DME for a beneficiary who is a patient in a type of facility that ordinarily provides the same type of DME item to its patients at no additional charge in the usual course of providing its services is excluded
* DME available to the beneficiary from a military hospital or clinic
* DME with deluxe, luxury, or immaterial features, which increase the cost of the item to the government relative to similar item without those features
* Routine periodic servicing, such as testing, cleaning, regulating, and checking, that the manufacturer doesn’t require be performed by an authorized technician
* Duplicate items of otherwise allowable DME to be used solely as a back-up to currently owned or rented equipment
* Expendable items, such as incontinent pads, diapers, ace bandages, etc.
* Non-medical equipment, such as humidifiers, electric air cleaners, stationary bikes, safety grab bars, etc.
Pro Tip
Don’t get confused, but some DME, such as wheelchairs and walkers, are also considered assistive equipment. Medicare considers commodes, wheelchairs, canes and scooters DME when they are medically necessary. Yet they also act as adaptive tools for seniors. For the most part, just remember that adaptive or assistive equipment isn’t medically required.
Receiving health insurance providers coverage for durable medical equipment typically looks like this
1. You get a medical justification letter from your medical provider that outlines why you need the item.
2. You choose a Medicaid-approved supplier and give them the letter.
3. The supplier fills out a prior approval application and sends it to the state Medicaid office.
4. The state Medicaid office either approves or denies the claim.
5. If it’s approved, the supplier sends you the DME and sends the bill to Medicaid.
6. If it’s denied, you will receive a letter outlining why, with the option to appeal.
Other Ways to Pay for Durable Medical Equipment
Sometimes health insurance providers won’t pay for the item you need, or maybe you just don’t want to wait to find out if what you need will be approved. In either case, below are some other ways to pay for durable medical equipment.
* Private insurance Private insurers typically cover durable medical equipment. Speak directly with your private insurer to find out details about coverage.
* Veterans health care Veterans and their spouses can turn to the Department of Veterans Affairs for help with a health insurance providers copayment for DME or with the entire cost of DME. The VA offers several programs, such as CHAMPVA benefits and Tricare.
* Private pay Paying out of pocket is an option, even if you have insurance. You may find it to be the quickest way to get the equipment you need. Be sure you understand the cost difference if you choose to pay for something privately that Medicaid, Medicare or another insurance policy normally covers. Buying DME secondhand often halves the cost, so check eBay, Facebook Marketplace, classified ads and thrift stores such as Goodwill.
* Nonprofit or state assistance Some nonprofits, national foundations and states help older adults pay for durable medical equipment through grants, low-interest loans, assistive technology programs and financial aid programs.
Pro Tip
Visit your state’s website or call your local Area Agency on Aging office for assistance in locating available state programs to help you get the equipment you need.
What Makes Equipment “Durable”
When we say “durable,” we’re talking about equipment that can withstand repeated use. It’s not something you use once and throw away. Instead, it’s built to last. For example, a wheelchair is designed to serve you for years, not just a few months. Medicare defines durable equipment as something that should last at least three years.
Medical Purpose
DME is not just any equipment. It has to serve a medical purpose. This means it’s essential for your health or helps you manage a medical condition. For instance, an oxygen tank provides the necessary support for someone with respiratory issues. It’s not about comfort or convenience; it’s about necessity.
Home Use
A key aspect of DME is that it’s intended for home use. This means the equipment is meant to be used in your everyday living space, not in a hospital or nursing home. Think of items like walkers or hospital beds that help you move around or rest comfortably at home
Long-term Support
Durable Medical Equipment is there for the long haul. It’s not a temporary fix but a long-term support system. Whether it’s helping you get around with a walker or monitoring your blood sugar with a glucose meter, DME is designed to assist you consistently over time.
Understanding these core aspects of DME can help you steer your healthcare options better. Knowing what qualifies as durable, medically necessary, and suitable for home use ensures you get the right support for your needs.
Approved suppliers
It’s important to verify that the supplier takes assignment—meaning they accept health insurance providers approved amount as full payment.
Face-to-Face Visit
For certain types of equipment, health insurance providers require a face-to-face visit with your doctor. This visit must occur within six months before your doctor writes the prescription. The purpose is to ensure that the equipment is needed to manage your specific medical condition. Your doctor will guide you on whether this step is necessary for the equipment you need.
What are some examples of DME not covered by health insurance providers
While Medicare covers many essential items, some are not eligible for coverage:
* Home Modifications Changes like ramps or widened doors are not covered, even if they improve accessibility.
* Comfort Items Equipment that provides comfort, such as air conditioners, is not covered.
* Disposable Supplies Items like incontinence pads and surgical masks, which are used once and discarded, are generally not covered. However, some exceptions apply if you’re receiving home health care.
* Prior Authorization You may need to get approval from your plan before obtaining certain equipment.
* In-Network Suppliers These plans might require you to use suppliers within their network. It’s crucial to verify that your chosen supplier is in-network to avoid unexpected costs.
* Plan-Specific Rules Each health insurance providers Advantage Plan can have unique guidelines, so it’s important to understand your plan’s specific requirements. Contact your plan provider to get detailed information on their DME coverage policies.
By understanding these guidelines you can better steer the process of obtaining the durable medical equipment you need
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Product Category
* Wheelchairs, walkers, and canes.
* Hospital beds and bedside commodes.
* Oxygen equipment and nebulizers.
* Diabetic supplies, shoes and compression stockings.
* Prosthetics and orthotics
* Wound Care
* Bracing
* Others