Medicare and DME

• by Christian Worstell
• September 13, 2023
• Reviewed by John Krahnert

In addition to covering a wide range of services, Medicare also covers certain medical devices, items and supplies often referred to as durable medical equipment (DME).

The Centers for Medicare & Medicaid Services (CMS) defines durable medical equipment as special medical equipment, such as wheelchairs or hospital beds, that are prescribed by your medical provider for use in your home.

Use this guide to learn more about durable medical equipment, including a list of some of the DME that Medicare covers and the estimated costs you can expect to pay.

What durable medical equipment does Medicare cover?

Medicare covers a range of items, supplies and equipment such as durable medical equipment.

The list of DME that is covered by Medicare includes (but is not limited to):

• Air-fluidized beds and various other support surfaces
• Blood pressure monitors
• Blood sugar monitors
• Blood sugar test strips
• Canes
• Catheters
• Cochlear implants
• Commode chairs
• Continuous passive motion machines
• Continuous Positive Airway Pressure (CPAP) devices and accessories
• Crutches
• Diabetic supplies
• Enteral nutrition supplies and equipment
• Glucose control solutions
• Hearing supplies
• Hospital beds
• Hyperbaric oxygen (HBO) therapy
• Infusion pumps and supplies
• Knee braces
• Lancets and lancet devices
• Nebulizers and nebulizer medications
• Ostomy supplies
• Oxygen equipment and accessories
• Pacemakers
• Patient lifts
• Prosthetic devices
• Suction pumps
• Traction equipment
• Wheelchairs
• Walkers

The classification of DME extends to DMEPOS, or durable medical equipment, prosthetics, orthotics and supplies. Items in this classification include prosthetics such as artificial limbs or other body parts, along with things like braces and wound dressings.

When does Medicare pay for DME?

In order for durable medical equipment to be covered by Medicare, the item in question must be:

• Durable, meaning it can withstand repeated use
• Used for a medical reason
• Not typically used by anyone who is not sick or injured
• Used in the home
• Expected to last for at least three years of use

How does Medicare cover DME?

Durable medical equipment is covered by Medicare Part B (medical insurance).

Once you meet your Part B deductible ($226 per year in 2023), you are typically required to pay a 20 percent coinsurance for the Medicare-approved cost for your qualified DME.

The following criteria must be met before Medicare will pay for your DME:

• The equipment must be considered medically necessary and prescribed for use in the home by a primary care physician. Most items will require your doctor to submit a Certificate of Medical Necessity (CMN).
  
  
• Your doctor must be approved by and accept Medicare. If your doctor accepts Medicare but does not accept Medicare assignment, they may be allowed to charge more than the Medicare-approved amount for your DME.
  
  
• The DME supplier must also be enrolled in Medicare.

Depending on the type of durable medical equipment, you may have to purchase or rent the item.

What is the Medicare Competitive Bidding Program?

Depending on where you live, the cost of your DME may be affected by the Competitive Bidding Program.

Under the program, DME suppliers submit a bid to Medicare to supply certain products to Medicare beneficiaries. Medicare then sets the amount it will pay for each item based on these bids.

Where can I find Medicare durable medical equipment?

Durable medical equipment can typically be obtained from three different types of providers, and each may carry a different cost for the same item.

Be sure to check with your doctor and your DME supplier to find out how much your equipment may cost.

• Participating providers
  A participating provider accepts the Medicare-approved amount as full payment for their equipment. The Medicare-approved amount is the amount of money that Medicare has determined it will pay for particular services and items.
  
  
• Non-participating providers
  A non-participating provider accepts Medicare patients, but does not accept the Medicare-approved amount as full payment.
  
  Non-participating providers reserve the right to charge you up to 15 percent more than the Medicare-approved amount for their durable medical equipment, which becomes your responsibility to pay.
  
  This extra charge is known as a Medicare Part B excess charge.
  
  
• Opt-out providers
  An opt-out provider has elected to opt out of Medicare entirely and does not accept Medicare insurance as payment.
  
  Medicare beneficiaries may still receive care from these providers but will not be able to pay for any services or items using their Medicare coverage.

You can enter your ZIP code and search the Medicare.gov Supplier Directory to find DME suppliers near you.

DME and Medicare Supplement Insurance

Medicare Supplement Insurance plans, or Medigap, provide coverage for many of the out-of-pocket costs that Medicare Part A and Part B don't cover.

Some Medigap plans can help cover some of the out-of-pocket costs associated with durable medical equipment. 

DME costs that may be covered by certain Medigap plans can include:

• Annual Part B deductible
  Before Part B will provide any coverage for DME, you must first meet an annual deductible of $226 in 2023.
  
  In other words, you must pay $226 out of your own pocket for covered medical equipment items before your Part B coverage takes effect.
  
  Medigap Plan C and Plan F both cover the Part B deductible. These two plans are no longer offered to new Medicare beneficiaries who became eligible for Medicare on or after January 1, 2020.
  
  If you already had Plan C or Plan F, you may keep it. If you became eligible for Medicare before Jan. 1, 2020, you may  be able to apply for Medigap Plan C or Plan F if either is available where you live.
  
  
• Part B Coinsurance
  After you meet your Part B deductible, you will typically be charged 20 percent of the Medicare-approved amount for a DME item.
  
  For example, if your medical equipment carries a Medicare-approved amount of $200 and you've already met your Part B deductible, you will be responsible for paying $40 (20 percent of $200).
  
  Each type of standardized Medigap plan provides at least some coverage for Part B coinsurance costs.
  
  
• Part B excess charges
  As mentioned above, when an item of DME is obtained from a non-participating provider, you may be charged up to 15 percent more than the Medicare-approved amount for your item.
  
  Medigap Plan F and Plan G each provide full coverage for Part B excess charges. 

Learn more about how Medicare Supplement Insurance can help cover durable medical equipment.

DME and Medicare Advantage plans

By law, Medicare Advantage plans are required to provide at least the same benefits as Medicare Part A and Part B (known together as Original Medicare).

This means that Medicare Advantage plans provide the same coverage for qualified DME as Original Medicare.

Medicare Advantage plans may also offer benefits not covered by Original Medicare that can help someone age in place at home. 

Ask a licensed insurance agent what additional benefits may be covered by the plans you are considering.

Find a Medicare Advantage plan that covers the DME you need

Are you looking for Medicare coverage for your approved DME? Do you want to find a plan that may also cover additional medical equipment that isn’t covered by Original Medicare? You may be able to find a Medicare Advantage plan that offers the benefits you need.

Call to speak with a licensed insurance agent who can help you compare Medicare Advantage plans that are available where you live.

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles he’s written, helping Americans better understand their health insurance and Medicare coverage.

Christian’s work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christian has written hundreds of articles for MedicareAvantage.com that teach Medicare beneficiaries the best practices for navigating Medicare. His articles are read by thousands of older Americans each month. By better understanding their health care coverage, readers may hopefully learn how to limit their out-of-pocket Medicare spending and access quality medical care.

Christian’s passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelor’s degree in journalism.

If you’re a member of the media looking to connect with Christian, please don’t hesitate to email our public relations team at Mike@tzhealthmedia.com.

 

 

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