Durable Medical Equipment (DME): Who Pays, How to Get it, Where to Find It!
Durable Medical Equipment: Who Pays, How to Get It, Where to Find it
In our previous Durable Medical Equipment (DME) related post we covered the what, who, and when of DME. Now let’s take it a step further and get down to specifics! First, we will cover the specific equipment identified by Medicare/Insurance/Medicaid as DME, who pays for it, and how/where to get it.
Here is a list of some equipment that is considered to be DME by the Center for Medicare Services (CMS):
Blood sugar monitors
Blood sugar (glucose) test strips
Continuous passive motion (CPM) machine
Infusion pumps and supplies
Manual wheelchairs and power mobility devices
Nebulizers and nebulizer medication
Oxygen equipment and accessories
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices
Medicaid considers augmentative/assistive communication devices and enteral nutritional supplements as DME also
Paying for DME
Only a Doctor can prescribe medical equipment if a patient intends for their insurance to assist in paying. The type of insurance dictates how much of the equipment cost is covered. There are requirements by each payer source.
Medicare Part A: Strict requirements including the patient being homebound and requiring skilled nursing care. As long as the DME is medically necessary and purchased from an approved supplier, Medicare Part A will pay 80% and the patient pays the remaining 20% and any amount over the allowable limit.
Medicare Part B: Pays for most equipment even if a patient isn’t homebound. The DME must be used in one’s home with the exception of a nursing home. If the equipment is medically necessary and purchased from a Medicare approved provider Medicare Part B will pay 80% of the allowable amount and the patient is responsible for the remaining 20% and any amount over the allowable limit.
Medicare Part C: Required to pay at least the same amount of Part A and B
Private Insurance: Typically will be covered if equipment is medically necessary, there is a predicted outcome, and a physician writes an order for it. The amount that is covered is dependent on specific insurer. Rental of DME is also covered provided the requirements are met.
Medicaid: While the specifics of payment depend on one’s state, Medicaid typically will cover the most basic equipment. For example, it may be determined that it is medically necessary that patient has an electric wheelchair. However, Medicaid may determine the patient only requires a less expensive model, such as a rear powered chair rather than a centered-powered chair. There are further programs, depending on state, that provide resources for patients to purchase DME.
The allowable limit is a maximum amount of money that Medicare-approved suppliers can charge for each type of DME. This amount is set by Medicare.
In the event that a provider sets a rate for a piece of equipment that is over the allowable limit, the patient may have to pay the remaining balance that is over the limit.
For Medicare beneficiaries, DME has to be purchased from a Medicare Participating Supplier that has been approved by Medicare in order to assure they will not pay more than the 20% copay of the approved provider rate. The following link can be used to search for Medicare Participating Suppliers by zip code:
For patients with private insurance/Medicaid it is recommended that you get a list of approved providers before purchasing equipment. The lists are usually different in each state.
For patients wishing to purchase DME privately, searching online often reveals the cheapest place to find equipment. In this case no prescription would be required, but it is recommended that a therapist evaluate the need for the equipment and do the fitting and training with a patient for optimal safety.
So when you put it all together what does it mean for your organization?
DME that increases patient safety increases successful outcomes for patients and therapists which is a win, win!
DME can reduce falls, pressure sores, and maximize function all of which are quality items that current Medicare legislation is looking into more and more in our health care environment.
The right equipment can prevent unnecessary hospital admissions or readmissions which impacts everyone’s bottom line.
DME has the ability to increase independence for patients, decreasing the need for outside assistance, and often times allowing patients to live in their desired location for longer!