Medicare coverage for durable medical equipment

Medicare defines durable medical equipment, or DME, as reusable medical equipment that has been deemed medically necessary. Your doctor or another health care provider determines what equipment you need per Medicare guidelines. He or she assesses your health condition, what equipment can be used in your home and what equipment you are able to use.

Medicare Part B will cover medically necessary durable medical equipment if you meet the coverage requirements.

To be covered by Medicare Part B, a durable medical equipment item must be:

• Prescribed by your doctor or health care provider
• Used because of an illness or injury
• Able and necessary to be used at home (though you may also use it outside your home)*
• Likely to last for three or more years
• Provided by certain medical suppliers approved by Medicare

*Note: If you live in a long-term care facility, then that’s considered your home by Medicare. However, if you are in a skilled nursing facility, then that facility is responsible for any DME it provides you.

Some examples of DME are walkers, hospital beds, home oxygen equipment, diabetes self-testing equipment (and supplies), and certain nebulizers and their medications (non-disposable). Wheelchairs and power scooters are also included in the list of DME, but additional rules apply. (See below.)

Generally speaking, Medicare pays for only one piece of DME for a particular health condition at any one time. Also, Medicare usually only pays for the most basic form of the equipment that’s needed.

While the list below is not complete, and other items may be covered, the below are some examples of common durable medical equipment items often covered by Medicare Part B.

Some examples of durable medical equipment covered by Medicare:

• Blood sugar monitors and test strips
• Canes
• CPAP devices [CPAP machines]
• Crutches
• Hospital beds
• Infusion pumps (some medicines need these)
• Nebulizers and nebulizer medications
• Oxygen equipment, supplies and accessories
• Power scooters
• Pressure-reducing beds and mattresses
• Prosthetics, orthotics (ex. brace) and supplies
• Suction pumps
• Walkers
• Wheelchairs

This is not a complete list, and some equipment items are subject to specific conditions for coverage. To see more, click here.

Medicare does also cover certain prescriptions, medications and supplies that you may use with your durable medical equipment item.

If you are uncertain whether you may be covered by Part B for an item on this list, it’s best to reach out to your plan provider. If you don’t see an item you need on this list, talk with your doctor or health care provider to see if it’s considered medically necessary and then with your plan provider to see if you’ll qualify for Medicare to cover it. Medicaid may offer coverage for some things Medicare may not, so keep that in mind if you have Medicaid as well.

There are some kinds of durable medical equipment and supplies that Medicare will not cover.

• Items that modify your home such as ramps or widened doors
• Equipment that is intended for use outside the home
• Durable medical equipment that is not suitable for at-home use such as paraffin bath units used in hospitals or skilled nursing facilities
• Most items that are considered as providing convenience or comfort (ex. air conditioners)
• Items that are thrown away after use or that aren’t used with equipment (ex. catheters)

Medicare may help pay for your manual wheelchair if all of the following conditions are met:

• Your health makes it hard to move around in your home. This means that even with the help of a walker or cane, you have significant problems in your home performing activities of daily living. These may include getting to the toilet, getting in and out of a bed or a chair, bathing and dressing.
• You can safely use the wheelchair yourself, or you always have someone with you to help you use it.
• Your doctor signs a written order for the equipment. You usually need to have a face-to-face examination with your doctor before he or she approves the order.
• You get equipment from a Medicare-approved supplier.

Medicare will only help pay for a scooter or power wheelchair for you if:

• You meet all the conditions for a manual wheelchair (see section above).
• You are unable to use a cane, walker or manual wheelchair, but are able to safely use a scooter or a power wheelchair.

In most cases, Medicare does not cover disposable medical supplies that are used once and then thrown away. However, some can be covered, such as supplies like test strips for diabetes. You’ll want to check with Medicare or your Medicare plan provider directly to see if the item you need is covered. Sometimes it may be that Part D provides coverage. For example, some diabetes supplies are also covered under Part D.

*Note: If you qualify for Medicare home health, Medicare may cover certain disposable supplies, such as intravenous supplies, gauze or catheters.

Original Medicare’s Part B covers durable medical equipment items when your Medicare-enrolled doctor or health care provider prescribes it for you to use at home. Once you have the doctor’s prescription, you can take it to any Medicare-enrolled supplier. Medicare pays 80 percent of its approved amount (after you meet your Part B deductible), and then you pay the 20 percent balance.

If your health condition changes and you need a different type of equipment, then you usually need a new prescription from your doctor for it to be covered.

Medicare Advantage (Part C) plans are required to cover everything that Original Medicare covers. This is true for both durable medical equipment and other benefits covered by the plan. The main difference between Original Medicare and Medicare Advantage lies in how you get a durable medical equipment item covered. For example, a Medicare Advantage plan may require prior authorization in order for items to be covered. You may also need to use a doctor and a Medicare-approved supplier who is in the plan’s network.