How to Get a Medical Device Approved Through Medicare

Medicare Part B and Medicare Advantage plans cover approved durable medical equipment (DME) and supplies.
DME items must be medically necessary and used at home.
Medicare only covers DME from Medicare-approved providers.
In general, covered equipment must be usable for at least 3 years.

Millions of Medicare beneficiaries rely on durable medical equipment (DME) every day. This includes canes, nebulizers, blood sugar monitors, and other medically necessary supplies to improve quality of life and maintain independence at home.

According to the latest Medicare Current Beneficiary Survey, nearly 30 percent of people on Medicare have trouble walking or climbing stairs. Assistive equipment such as canes, walkers, and wheelchairs are crucial in maintaining mobility at home.

Although DME accounts for only 2 percent of total healthcare costs in the United States, these supplies are important in preventing injuries and to support the health of millions on Medicare.

Original Medicare and Medicare Advantage plans pay for some of the costs of equipment and supplies. This equipment must be used at home for a medical purpose and for repeated use. Out-of-pocket costs vary depending on the plan and whether you are renting or buying the equipment.

Let’s look at what DME products are covered by Medicare and the best way to get them.

What does Medicare cover for medical devices?

Medicare defines DME as devices, supplies, or equipment that are medically necessary to maintain daily activities safely in the home. Medicare does not cover DME during a short-term stay at a skilled nursing facility or hospital. However, Medicare does consider these facilities your home when you live there long-term and will cover DME.

In most cases, the covered equipment or device must be meant for repeated use and is not disposable like catheters (which are not covered).

DME items are meant to help you manage a health condition, recover from an injury or illness, or recover from surgery. They should also help you safely perform the activities of your daily life.

Medicare only pays for the basic level of DME products available for any given condition. Every time you need new equipment, your doctor must provide a document stating its medical necessity for your condition.

Some of the covered products include:

diabetic supplies
canes, crutches, and walkers
wheelchairs and mobility scooters
continuous positive airway pressure (CPAP) devices
commode chairs
nebulizers and nebulizer medications
oxygen and related supplies
hospital beds

DME coverage also includes orthotics, braces, prosthetics, and wound dressings. For a full list of covered products, check Medicare’s DME coverage information here.

If you have original Medicare, your DME supplies for home use will be covered by Medicare Part B, as long as all eligibility requirements are met.

Medicare Advantage plans must also cover at least the same DME products covered by original Medicare, but there may be specific restrictions. In some cases, Medicare Advantage plans may cover more supplies than original Medicare, but you may have to meet a deductible before the plan pays for DME.

What are the eligibility rules?

Original Medicare rules

You are eligible for DME benefits if you are enrolled in original Medicare and meet certain other Medicare rules for coverage.

Medicare Part B covers DME for home use when a doctor orders the equipment after a face-to-face visit. Your doctor may need to fill out a certificate of medical necessity for some DME products to be covered. Also, in-person visits must be within 6 months of the order for the DME product.

Devices are not covered unless you have been injured or have a medical condition that requires therapeutic equipment.

There are different coverage rules for products like power mobility devices — including motorized wheelchairs or scooters — as well as some other DME products.

Medicare requires you to go to approved healthcare providers and device suppliers for full coverage.

Medicare Advantage rules

Medicare Advantage (or Part C) plans have many of the same eligibility requirements, but there are some differences.

Depending on the specific plan, Medicare Advantage plans may:

have higher costs
cover more products
require the use of in-network providers
use separate suppliers for different types of equipment

You can contact the plan provider for a list of approved DME suppliers in your area. You can also ask about coverage of specific items, costs, and any special requirements.

Can I rent or buy my equipment?

In general, most DME equipment is rented. A Medicare-approved supplier will know if you can buy an item. Original Medicare pays 80 percent of the monthly costs for 13 months of rental. If you still need the equipment after this time, depending on the type of product, you may be allowed to own it. Your supplier will let you know if the equipment will need to be returned.

There are some exceptions to renting. If the equipment is made specifically to fit you, like a prosthetic, Medicare requires you to buy this type of product.

In some cases, Medicare lets you decide if you want to rent or buy the equipment, for example, items that cost less than $150. If you choose to purchase equipment, you may have to pay the full amount and seek reimbursement from Medicare. We’ll go over the reimbursement process later.

There are special rules for oxygen equipment. You can only rent this equipment, and supplier agreements are for a 5-year time frame. Medicare pays 80 percent of the rental fees for the oxygen and any supplies for 36 months. You must still pay the 20 percent coinsurance each month.

If you still need oxygen therapy after 36 months, you no longer have to pay rental fees. You must, however, pay the coinsurance for oxygen and any maintenance on the equipment.

How to rent equipment

In most cases, DME equipment is rented, not purchased, unless it is made specifically for you. The process for eligibility is the same as for buying DME. After visiting the doctor to get an order, you can take the prescription for DME to an approved supplier to rent the equipment.

Keep in mind that Medicare Advantage plans may have specific rental requirements, like using an in-network supplier or renting a specific device brand or manufacturer. You can check with your plan to find out what the specific rules are for coverage.

How to buy equipment

Medicare Part B will pay for the covered cost of equipment. Here are the steps you need to take to purchase equipment:

Go to an in-person doctor visit, where your doctor will write an order for the DME.
Take the order to a Medicare-approved DME supplier.
Depending on the product, ask the supplier if they will deliver it to your home.
Find out if Medicare requires prior authorization for your DME.

Medicare Advantage plans may have specific requirements based on individual plans and regions. Some plans may require you to:

buy specific brands or manufacturers of DME
pay deductibles before DME is covered
visit in-network providers for supplies
get prior authorization

Contact your Medicare Advantage plan directly to ask what is covered and about the associated costs.

Deciding whether to rent or buy

There may be some cases when you have a choice to buy or rent DME. Here are a few points to consider to help you decide which choice makes sense for you:

How long will you need the equipment?
What is the upfront cost of buying versus monthly rental fees?
What are the costs of repair if you buy?
Can you easily sell the item after use?

Considering the upfront costs, repair costs, and how useful the product will be long-term can be helpful in making the decision to buy versus rent.

What are the costs?

Costs of DME depend on a few different factors like the type of plan you have (original Medicare vs. Medicare Advantage), whether you’d like to buy or rent, whether you use Medicare-approved providers, and even where you live.

Medicare requires you to purchase all DME supplies from providers that accept assignment. Those who agree to “accept assignment” have signed agreements that they’ll accept the rates set by Medicare. This keeps costs low both for you and for Medicare.

If you buy or rent supplies from a non-participating provider, you may have to pay a higher amount that Medicare will not reimburse. Avoid using non-approved suppliers except under certain special circumstances, such as an emergency. Always check with a supplier that they accept assignment first.

Part A

Medicare Part A covers hospital stays, hospice care, and limited home health and skilled nursing facility care. If DME supplies are required during your stay at any of these facilities, Medicare expects the provider to pay for these costs based on your Part A benefits.

Part B

Eligible DME costs are covered under Medicare Part B from an approved provider who accepts assignment. Regardless of whether you rent or buy equipment, Medicare pays 80 percent of costs after you meet your deductible. You then pay 20 percent coinsurance and your monthly premium costs.

In 2020, the deductible is $198 and the monthly premium is $144.60 for most people. Unless you have supplemental insurance, such as Medigap, you will pay the balance or 20 percent for any covered DME products.

Medicare Advantage

Medicare Advantage plans also cover at least the same DME products as original Medicare. However, there may be differences in cost and restrictions on providers. These plans may offer more products, but your options for buying versus renting may be different based on specific plan rules.

Reach out to your plan regarding your DME needs and ask about costs and coverage. If you live in multiple states during the year, ask about product servicing and delivery options to avoid gaps or higher costs with service. If you switch plans, check to make sure your equipment will be covered before switching to avoid any extra costs or coverage gaps.

Medigap

Medigap is supplemental insurance you can buy to help pay coinsurance and copayment costs not covered by original Medicare. Since Medicare Part B pays 80 percent of covered DME costs, a Medigap plan may be a good option to help pay some, or all, of the balance of your DME products.

There are 10 plans available, and coverage and costs vary by plan. Choose the best plan for you based on your medical needs and budget.

Medigap plans do not start paying for copayment benefits like the 20 percent owed for DME until you meet your original Medicare (Part A and Part B) premiums and deductibles.

What if I need to file a claim for reimbursement?

You rarely need to file a claim yourself for a DME product or supply. The DME provider will file claims for your supplies if you have original Medicare.

All claims must be filed within 1 year of rental or purchase for Medicare to reimburse it. You can find more information here on the process of filing a claim.

Check your Medicare Summary Notice statements to make sure the provider filed the claim. If your provider has not filed a claim, you can call and ask them to file. If time is running out on your 1-year limit, you can file a claim using the Patient Request for Medical Payment form.

You can also call 800-MEDICARE or visit Medicare.gov for help with questions on filing a claim or other questions about DME products.

The takeaway

Original Medicare and Medicare Advantage plans pay for covered DME products and supplies, as long as you meet eligibility requirements. Medicare Advantage plans may offer more options for DME products, but costs and coverage vary by plan and region. A Medigap plan can help offset the costs of your coinsurance from original Medicare.

Although a majority of DME products are rented, you may have an option to buy equipment based on the specific product and your insurance.

For DME to be covered, it must be:

for a medical purpose and used at home
reusable and last at least 3 years
rented or purchased from Medicare-approved providers or in-network Medicare Advantage plan providers

You can reach out to your local State Health Insurance Assistance Program (SHIP) for more information on what is covered and how to get a DME product from a supplier in your area.

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