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Insurance Coverage FAQs For Durable Medical Equipment (DME)

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Durable medical equipment (DME) includes a variety of long-term use equipment such as hospital beds, mobility aids (walkers, scooters, wheelchairs), personal care aids (bath chairs, commodes, dressing aids), prostheses (artificial limbs), orthotics (therapeutic footwear), oxygen concentrators and other items. The out-of-pocket expense you pay for a specific item will depend on your insurance, the cost of the item, and whether the doctor or equipment supplier agrees to accept the Medicare-approved amount as full payment. But in order to get a general idea of insurance coverage for durable medical equipment, take a look at our frequently asked questions below:

Is a doctor’s referral required for insurance coverage of Durable Medical Equipment (DME)?

Yes, most insurance providers require a detailed prescription from a doctor, physician’s assistant, or certified nurse practitioner for the coverage of durable medical equipment.

Will private insurance cover DME?

Most private insurance providers will not cover the entire cost of durable medical equipment. They generally approve only the lowest level of equipment or compensate a modest portion of a more expensive item. Of course, equipment eligibility and coverage varies from policy to policy, so contact your provider for specifics.

Will long-term care insurance cover DME?

Most long-term care policies pay out specific daily dollar amounts, but the definition of long-term care varies with each policy. Durable medical equipment is usually considered a covered long-term care expense, but confirm with your provider if you already have a policy in place. Purchasers of new long-term care policies are encouraged to ensure durable medical equipment is an allowable expense.

Does Medicare cover DME?

All Medicare Part B patients are covered for durable medical equipment that meets the following criteria:

  • The item is used for a medical reason in your home
  • The item is durable/long-lasting (expected lifetime of at least 3 years).

DME is only partially covered under Medicare Part A if the patient qualifies for the Home Health Benefit (meaning the patient is incapable of leaving his or her residence and requires skilled nursing care).

What is my cost with Medicare?

Typically, when a supplier accepts the Medicare-approved amount as full payment, you only pay 20% of that (although your Medicare Part B deductible will apply). But keep in mind that Medicare covers rental and purchase of durable medical equipment differently, and your doctor must be enrolled in Medicare for your claim to be accepted.

Does Medicaid cover DME?

Medicaid usually covers a wider selection of equipment and supplies and a larger portion of the expense than Medicare, but note that eligibility rules, coverage, and benefits are determined at the program level by each individual state.

Does VA insurance cover DME?

TRICARE, the primary insurance provider for the Department of Veterans’ Affairs, covers most durable medical equipment that:

  • Improves, restores, or maintains the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient’s function or condition
  • Maximizes the patient’s function consistent with the patient’s physiological or medical needs
  • Provides the medically appropriate level of performance and quality for the medical condition present

TRICARE covers durable medical equipment rentals and purchases, but the specifics of each case are decided by the regional contractor.

At PA Healthcare, we now accept Medicare, TRICARE, and private insurance!

At PA Healthcare in San Diego, we offer walkers, wheelchairs, scooters, rollators, hospital beds, and other durable medical equipment for rent and purchase. For more information about your plan’s coverage of specific items, please give us a call. Have your insurance information ready.

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