Medicare Guidelines

Medicare Guidelines

Medicare, as you can imagine, has detailed guidelines about what qualifies for coverage for Durable Medical Equipment (DME), which is reusable equipment: walkers, wheelchairs, beds, commodes, mattresses, power mobility, oxygen, CPAP, Bi-PAP, nebulizers, etc. To link to a Medicare Booklet on DME, click here.

1. Medicare Part B (Medical Insurance)

Anyone who has Medicare Part B (Medical Insurance) can get DME as long as the equipment is medically necessary.

Medicare Part B covers DME when your doctor or treating practitioner (like a nurse practitioner, physician assistant, or clinical nurse specialist) prescribes it for you to use in your home. A hospital or nursing home that’s providing you with Medicare-covered care can’t qualify as your “home” in this situation. However, a long-term care facility can qualify as your home.

Medicare Advantage Plans (like an HMO or PPO) must cover the same items and services as Original Medicare. Your costs will depend on which plan you choose, and may be lower than Original Medicare. If you’re in a Medicare Advantage Plan and you need DME, call your plan to find out if the equipment is covered and how much you’ll have to pay. If you’re getting home care or using medical equipment and you choose to join a new Medicare Advantage Plan, you should call the new plan as soon as possible and ask for “Utilization Management.” They can tell you if your equipment is covered and how much it will cost. If you return to Original Medicare, you should tell your supplier to bill Medicare directly after the date your coverage in the Medicare Advantage Plan ends.

If you need DME in your home, your doctor or treating practitioner (like a nurse practitioner, physician assistant, or clinical nurse specialist) must prescribe the type of equipment you need by filling out a detailed written order. For some equipment, Medicare may also require your doctor to provide additional information documenting your medical need for the equipment to get approval for the equipment. Your supplier will work with your doctor to be sure that all required information is submitted to Medicare. If your prescription and/or condition changes, your doctor must complete and submit a new, updated prescription. Medicare only covers DME if you get it from a supplier enrolled in Medicare. This means that the supplier has been approved by Medicare and has a Medicare supplier number.

A supplier enrolled in Medicare (Med One) must meet strict standards to qualify for a Medicare supplier number. If your supplier doesn’t have a supplier number, Medicare won’t pay your claim, even if your supplier is a large chain or department store that sells more than just DME.

2. What’s “assignment” in Original Medicare, and why is it important?

Assignment is an agreement between you (the person with Medicare), Medicare, and doctors or other health care providers, and suppliers of health care equipment and supplies (like durable medical equipment (DME) and prosthetic or orthotic devices). Doctors, providers, and suppliers who agree to accept assignment accept the Medicare-approved amount as full payment. After you have paid the Part B deductible, you pay the doctor or supplier the coinsurance (usually 20% of the approved amount). Medicare pays the other 80%. To get current year amounts, see the “Costs at a Glance” page on Medicare.gov.

Suppliers who agree to accept assignment on all claims for DME and other devices are called “participating suppliers.” If a DME supplier doesn’t accept assignment, there’s no limit to what they can charge you. In addition, you may have to pay the entire bill (Medicare’s share as well as your coinsurance and any deductible) at the time you get the DME. The supplier will send the bill to Medicare for you, but you’ll have to wait for Medicare to reimburse you later for its share of the charge.

3. What about power mobility?

For Medicare to cover a power wheelchair or scooter, your doctor must state that you need it because of your medical condition. Medicare won’t cover a power wheelchair or scooter that’s only needed and used outside of the home. Most suppliers who work with Medicare are honest. There are a few who aren’t honest. Medicare is working with other government agencies to protect you and the Medicare Program from dishonest suppliers of power wheelchairs and scooters.

4. How will I know if I can buy durable medical equipment (DME) or whether Medicare will only pay for me to rent it?

If your supplier is a Medicare-enrolled supplier, they’ll know whether Medicare allows you to buy a particular kind of DME, or just pays for you to rent it. Medicare pays for most DME on a rental basis. Medicare only buys inexpensive or routinely bought items, like canes; scooters; and, in rare cases, items that must be made specifically for you.

5. Buying equipment

If you own Medicare-covered DME and other devices, Medicare may also cover repairs and replacement parts. Medicare will pay 80% of the Medicare-approved amount for purchase of the item. Medicare will also pay 80% of the Medicare-approved amount (up to the cost of replacing the item) for repairs. You pay the other 20%. Your costs may be higher if the supplier doesn’t accept assignment. Note: The equipment you buy may be replaced if it’s lost, stolen, damaged beyond repair, or used for more than the reasonable useful lifetime of the equipment.

6. Renting equipment

If you rent DME and other devices, Medicare makes monthly payments for use of the equipment. The rules for how long monthly payments continue vary based on the type of equipment. Total rental payments for inexpensive or routinely bought items are limited to the fee Medicare sets to buy the item. If you’ll need these items for more than a few months, you may decide to buy these items rather than rent them. Monthly payments for frequently serviced items, like ventilators, are made as long as the equipment is medically necessary. The payment rules for other types of rented equipment, called “capped rental items,” are on page 9. You pay 20% of the Medicare-approved amount after you pay your Medicare Part B deductible for the year. Medicare pays the other 80%. The supplier will pick up the equipment when you no longer need it. Any costs for repairs or replacement parts for the rented equipment are the supplier’s responsibility. The supplier will also pick up the rented equipment if it needs repairs. You don’t have to bring the rented equipment back to the supplier.

7. How does Medicare pay the supplier for oxygen equipment and related supplies?

If you have Medicare and use oxygen, you’ll rent oxygen equipment from a supplier for 36 months. After 36 months, your supplier must continue to provide oxygen equipment and related supplies for an additional 24 months. Your supplier must provide equipment and supplies for up to a total of 5 years, as long as you have a medical need for oxygen.

8. What do I pay the supplier? What does the rental payment cover?

The monthly rental payments to the supplier cover not only your oxygen equipment, but also any supplies and accessories like tubing or a mouthpiece, oxygen contents, maintenance, servicing, and repairs. You pay 20% of the Medicare-approved amount after you pay your Medicare Part B deductible for the year. Medicare pays the other 80%.

If you have further questions about the cost of DME or Medicare coverage, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.