Does Health Insurance Cover Medical Devices?

by Team eLocal
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If you need durable medical equipment to manage a health condition, having the correct insurance coverage can be reassuring. Here’s a breakdown of what private insurance, Medicare and Medicaid cover.

What Is Durable Medical Equipment?

Durable medical equipment (DME) is any item that can withstand repeated use and serves a medical purpose. Therefore, the term doesn't usually cover disposable, single-use medical supplies such as dressings and catheters.

Furthermore, equipment doesn't usually qualify as DME unless its purpose is solely medical. In other words, an item isn't usually DME if it has a non-medical use, even if it provides a medical benefit for specific conditions. For example, insurers won't usually approve an air conditioner as DME for an enrollee with a health condition exacerbated by high temperatures. However, some carriers make exceptions for certain items, such as gel pads and heat lamps.

Definitions of DME may vary between carriers. However, it may include the following:

  • Blood sugar monitors
  • Mobility aids, such as canes, crutches, walkers and scooters
  • Hospital beds
  • Nebulizers
  • Suction pumps
  • Infusion pumps
  • Continuous positive airway pressure (CPAP) machines
  • Oxygen equipment
  • Commodes

Does Health Insurance Cover Durable Medical Equipment?

Many private health insurance policies cover DME, but it isn't a mandatory benefit. You can find out whether your plan covers DME and which items it covers by calling your insurer or checking your insurance documents.

Generally, you'll need a prescription from your provider explaining the medical need for your equipment before your carrier will approve coverage. Some insurers cover the purchase of DME, while others may only cover rental costs.

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Does Medicare Cover Durable Medical Equipment?

Medicare Part B covers DME for home use if it's medically necessary. However, you'll only be eligible for coverage if your prescribing doctor is enrolled in Medicare and you get your DME from a Medicare-approved supplier.

Medicare's definition of DME is relatively broad. It covers medically necessary assistive technologies, such as mobility aids, and medical equipment for home use, such as nebulizers and insulin pumps. However, enrollees may also be eligible for prosthetics, orthotics and supplies coverage. Examples include:

  • Prosthetic devices to perform the function of internal organs
  • Artificial limbs and eyes
  • Limb, back and neck braces
  • Medical supplies (when used alongside medical equipment)

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However, there are also Medicare DME exclusions. Medicare doesn't usually cover mobility aids unless you need them to move around your home. It also excludes equipment unsuitable for home use or equipment designed to make life comfortable without a clear medical benefit, such as specialized bathtubs. You can't claim for single-use supplies used independently of medical equipment, such as incontinence pads, unless you receive home health care.

Rules for DME coverage depend on the type of equipment. Medicare covers the purchase of some items, while others may only qualify for rental coverage. Furthermore, your DME must have an expected lifespan of at least three years. 

Medicare starts paying for DME once you meet your annual deductible. You'll pay 20% of the Medicare-approved amount for your equipment, and Medicare covers the remaining 80%.

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Does Medicaid Cover Durable Medical Equipment?

Medicaid coverage rules for DME vary between states, but it usually covers medically necessary DME. Each state can decide which DME items to cover via its Medicaid program, but most cover equipment that can withstand repeated use, has a primarily medical purpose and is mainly useless to people without a medical need for it.

Often, state Medicaid programs include assistive technologies such as electric wheelchairs under the DME umbrella. However, most programs only cover cost-effective options. For example, a state Medicaid program may agree to cover a basic electric wheelchair, but it's unlikely to approve funding for an expensive, technologically advanced model.

Generally, skilled nursing homes manage the acquisition of DME for residents enrolled in Medicaid. However, you may need to manage the process yourself if you're a Medicaid at Home enrollee. Your doctor will write a medical justification letter explaining why you need the equipment, and you must forward the letter to a Medicaid-approved supplier.

After receiving the letter, the supplier will apply for Medicaid approval. Once approved, you'll receive your DME, and the supplier will bill Medicaid directly.

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