Durable Medical Equipment: What's Covered by Medicare?

Medicare Part B covers durable medical equipment (DME), which is equipment that helps you complete your daily activities. Medicare usually covers DME if the equipment: 

• Is durable, meaning it is able to withstand repeated use
• Serves a medical purpose
• Is appropriate for use in the home, although you can also use it outside the home
• Is likely to last for three years or more

There are many important things to know about Medicare’s coverage rules for DME and how to access the equipment you need.

What kind of durable medical equipment does Medicare cover? 

Whether you have Original Medicare or a Medicare Advantage Plan, the types of Medicare-covered equipment should be the same. Examples of DME include wheelchairs, walkers, hospital beds, power scooters, and portable oxygen equipment. Medicare Part B also covers prosthetic devices that replace all or part of an internal bodily organ; prosthetics, like artificial legs, arms, and eyes; orthotics, like rigid or semi-rigid leg, arm, back, and neck braces; and certain medical supplies.

Medicare also covers certain prescription medications and supplies that you use with your DME, even if they are disposable or can only be used once. For example, Medicare covers medications used with nebulizers, as well as lancets and test strips used with diabetes self-testing equipment.

To find out if Medicare covers the equipment or supplies you need, call 1-800-MEDICARE or visit www.medicare.gov. You can also learn about Medicare coverage of DME by contacting your State Health Insurance Assistance Program (SHIP) at www.shiphelp.org or 877-839-2675.

What kind of durable medical equipment does Medicare not cover?

There are certain kinds of equipment and supplies that Medicare does not cover, such as equipment mainly intended to help you outside of the home or items that get thrown away after use or are not used with equipment. Medicare’s DME coverage additionally does not include most items intended only to make things more convenient or comfortable, modifications to your home, or equipment that is not suitable for use in the home. Examples of equipment that is not DME: surgical facemasks, incontinence pads, bathtub and toilet seats, wheelchair ramps, and wheelchairs or scooters that are only intended for use outside the home.

Note that some Medicare Advantage Plans may cover minor home modifications or other items as a supplemental benefit. Also, Medicaid may cover some forms of equipment that Medicare will not cover.

How can I get durable medical equipment covered by Medicare?

DME must be prescribed by your primary care provider, or PCP. Your PCP must sign an order, prescription, or certificate. In this document, your PCP must state that you need the requested DME to help a medical condition or injury, that the equipment is for home use, and that, if applicable, a face-to-face visit occurred. Your face-to-face visit, when required, must take place no more than six months before the prescription is written. Your provider should know if Medicare requires a face-to-face visit for the item you need. 

Once you have your PCP’s order or prescription, you must take it to the right supplier to get coverage. Note that if you need coverage for a manual or power wheelchair or scooter, the process is different and may require your PCP to send a prior authorization request to Medicare. 

Which suppliers should I go to for my durable medical equipment?

If you have Original Medicare, you should get your DME from a Medicare-approved supplier that takes assignment. Providers who take assignment cannot charge you more than 20% of Medicare’s approved amount for the cost of the DME. You can call 1-800-MEDICARE for a list of these suppliers in your area. 

Be aware that many suppliers are Medicare-approved but do not take assignment. These suppliers may charge you more than Medicare’s approved amount for the cost of services. Medicare will still only pay 80% of its approved amount for the DME, so you will be responsible for any additional costs. 
    
You should also avoid suppliers who have not signed up to bill Medicare for DME, also known as opt-out providers. Medicare will not pay for services you receive from opt-out providers. This means you are responsible for the entire cost. 

If you have a Medicare Advantage Plan, you must follow the plan’s rules for getting DME. Your plan may require that you receive approval from the plan before getting your DME, use a supplier in the plan’s network of suppliers, or use a preferred brand of DME. Contact your plan to learn more about its DME coverage rules. 

What are the costs associated with durable medical equipment? 

Original Medicare normally pays 80% of the Medicare-approved amount after you meet your Part B deductible, and you are responsible for a 20% coinsurance. Your costs will also depend on whether Medicare requires that you rent or buy the equipment you need.

Most equipment is initially rented, including many manual and power wheelchairs. In certain situations, Medicare may require that you buy your DME, such as an item that is made to fit you. Medicare allows you a choice as to rent or buy certain items, such as some power wheelchairs, items costing less than $150, and parenteral/enteral infusion pumps. There are also different rules when you need oxygen equipment.

For more information on the costs of your specific equipment, contact your doctor and DME supplier. If you have a Medicare Advantage Plan, your plan will have its own cost and coverage rules for DME. Contact your plan for more information.

How to get started with Medicare coverage for durable medical equipment

In summary, here are a few ways to get started with Medicare coverage of durable medical equipment. 

• If you need DME, first speak with your doctor or other health care provider. Remember that an order from your doctor is required for Medicare to cover your DME.
• If you have Original Medicare, make sure to use Medicare-approved DME suppliers that take assignment. You can call 1-800-MEDICARE to request a list of these suppliers in your area. 
• If you have a Medicare Advantage Plan, call your plan directly to learn about any additional DME coverage rules or requirements for the equipment you need. You can also request a list of in-network DME suppliers. 
• If you have questions about how Medicare covers DME, or if you need help finding a supplier or appealing a denial of coverage, contact your State Health Insurance Assistance Program (SHIP). To find your local SHIP, visit www.shiphelp.org or call 877-839-2675.

Watch this short video explaining how durable medical equipment works in Medicare: