If you’ve ever had major surgery, suffered a serious injury, or battled a major illness, you may have used durable medical equipment (DME). This consists of various things (a wheelchair, a scooter, a hospital bed, etc.). If you find yourself needing this equipment, then you’re probably also wondering if there’s medicare coverage for durable medical equipment.
The type of DME your physician may prescribe is defined as equipment that will be used repeatedly, and is not disposable. It is generally not applicable to someone who does not have an illness or injury. And it is often partially covered by Medicare, with a portion of the DME remaining a patient’s responsibility.
Coverage of Durable Medical Equipment
DME is covered under Medicare Part B when your medical provider prescribes it for you to use in your home. It does not matter if you live in a private home, assisted living facility, or a long-term care facility – they are all classified as your home.
The only difference is if you reside in a skilled nursing facility (SNF), you are covered under Medicare Part A, and the SNF is responsible for providing the DME that you need while you are there.
If you have Original Medicare, a physician or other clinical nurse specialist will prescribe the required DME. The provider will do this by filling out an order, though some equipment will need additional information that only a physician can fill out.
Medicare Advantage covers the same DME as original Medicare but may have different deductibles. Your specific plan will dictate the actual cost of the item.
To see if you qualify for your specific DME, you need to contact the Primary Physician assigned under your Medicare Advantage plan. They will let you know if it is covered and what portion of the price you will pay. You will also have to use a Medicare DME company approved within your plan’s network.
The Cost That You are Required Pay for Durable Medical Equipment
Medicare only covers DME from a Medicare provider, so it is crucial to determine if the company providing your equipment is Medicare-approved and has a Medicare number.
Generally speaking, under original Medicare, most DME is an 80/20 split, with you being responsible for 20% of the cost of the item. However, each item and insurance plan can look different.
Medicare Coverage of Walkers
Walkers will be covered if you have an injury that makes it difficult to walk, or you have a loss of balance, weakness, or another reason that you require a walker.
A physician will authorize the order, as with all of the equipment, and the Medicare DME will provide your walker. There are many different types of walkers, and your physician will determine which type is most suited to your specific needs.
Medicare Coverage of Wheelchairs
A manual wheelchair will be covered once every five years if deemed medically necessary. To have a wheelchair covered, it must be for in-home use, not just for use outside of the home.
The diagnosis must show that you cannot walk or have a disease that makes walking difficult. Some possible diagnoses can be:
- Multiple Sclerosis (MS)
- Parkinson’s Disease
- Cerebral Palsy
- Muscular Dystrophy
- Stroke-related paralysis
- Spinal Cord Injuries
- Alzheimer’s Disease
- And many other diseases that affect your ability to walk.
Medicare Coverage of Scooters or Power Wheelchairs
Medicare will only cover a power wheelchair or scooter if your doctor states you need it for your medical condition. Medicare looks at scooters with increased scrutiny.
These power wheelchairs and scooters are very expensive, and Medicare does not want to provide them for someone who truly does not need this medical equipment.
To qualify for a scooter or power wheelchair, you must meet all of these requirements:
- You have an illness or injury that causes significant difficulty moving about within your home (not just outside).
- You cannot perform your activities of daily living – things like bathing, transferring out of bed, a chair, or going to the bathroom with the use of a cane, walker, crutch, or manual wheelchair independently.
- You can safely operate the scooter and get off or onto the wheelchair.
- If you cannot get on and off the scooter safely, someone is always available to help you do this task.
- You can safely get through your home with the equipment. It must fit through doorways and get over surfaces.
An additional note is that Medicare does not cover renovations to your home. So, the scooter must safely maneuver through your home.
Medicare Coverage of a Hospital Bed
Sometimes you have a condition that requires the use of a specialized hospital bed.
Medicare will look closely at ensuring that this is essential and will be necessary for you to live at home. Medicare will cover 80% of a hospital bed if you meet the following criteria:
- You have a medical condition that requires a hospital bed.
- The illness is not limited to this but could include trouble breathing, swollen feet and legs, a wound, or a greater risk of falling. The doctor will describe the condition that requires you to have a hospital bed.
- You are under a doctor’s care and seen at least every six months.
- The doctor will see you for the condition that causes you to need a hospital bed and continue to document this need.
- Your Doctor and the DME provider are Medicare Providers.
- If you choose to use someone not a Medicare participant, you may have increased charges.
We have gone through a lot of information, and as you can see, Medicare does not cover the entire cost of the Durable Medical Equipment. Other organizations can help if it seems too difficult to pay for your equipment, talk to your physician, the DME provider, or your case manager to see what your options are for your equipment coverage.
Please refer to the Medicare Coverage of Durable Medical Equipment & other Devices booklet for more information on Medicare requirements.
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