Durable Medical Equipment

How much does Medicare pay for covered items?

Medicare Part B helps pay for medically-necessary items. First, your Medicare Part B deductible—set at $147 in 2013—applies and must be paid in full. Once the deductible is met, Medicare Part B covers 80% of approved costs. This means that, on top of the deductible, you can expect to pay 20% of Medicare-approved costs out-of-pocket. If you are enrolled in a Medicare Advantage plan, the same items of durable medical equipment are covered under your plan as under Original Medicare (Medicare Part A and Medicare Part B). Medicare Advantage plans are required to cover the same items that Original Medicare covers, including DME. However, cost obligations under Medicare Advantage can vary, so it is important to check with your Medicare Advantage plan concerning costs associated with purchase or rental of durable medical equipment. CMS advises anyone enrolled in a Medicare Advantage plan to call the telephone number on their Medicare Advantage plan card and to ask for “Utilization Management” in order to get information about DME as it pertains to their particular Medicare Advantage plan. Medicare supplement plans vary, but under some plans out-of-pocket costs associated with purchase or rental of durable medical equipment can be eliminated altogether. Medicare supplement (or Medigap) Plan F, for example, is specifically designed to fill all the high-risk gaps in basic Medicare coverage. Plan F covers all Medicare-approved costs not covered by Medicare Part A and Medicare Part B, and will eliminate your need to pay deductible and coinsurance costs associated with purchase or rental of medically-necessary durable medical equipment.

What exactly does “medically-necessary” mean?

Your doctor or treating practitioner must determine that a particular item of DME is required for your use at home. According to CMS, qualified treating practitioners include nursing practitioners, physician assistants, and clinical nurse specialists. Your doctor or practitioner must prescribe the item for use in the home. If the item is determined by your doctor or practitioner to be necessary only outside the home, Medicare will not cover the item.

Hospitals and nursing homes do not qualify as “home.” If you require items of durable medical equipment in a hospital or nursing home, it is not your responsibility to initiate rental or purchase of those items. However, long-term care facilities do qualify as “home,” and any medically-necessary and Medicare-approved item of DME prescribed for your use in a long-term care facility is covered by Medicare.