Does Medicare Part A Cover Durable Medical Equipment?

Understanding Medicare coverage for medical equipment can seem intricate. This article clarifies Medicare Part A’s role in durable medical equipment (DME) coverage and guides individuals toward the primary sources of support for such items.

Defining Durable Medical Equipment

Durable Medical Equipment (DME) refers to reusable medical equipment that a doctor prescribes for use in the home. For an item to qualify as DME under Medicare guidelines, it must meet specific criteria. The equipment needs to be durable, meaning it can withstand repeated use and is expected to last for at least three years. It must also be used for a medical purpose, serving to treat an illness or injury.

Furthermore, DME is generally not useful to someone who is not sick or injured, indicating its medical utility. The equipment must also be appropriate for use in the home setting. Common examples of DME include wheelchairs, walkers, oxygen equipment, hospital beds, blood sugar monitors, and nebulizers.

Medicare Part A and DME Coverage

Medicare Part A primarily covers inpatient hospital stays, care received in a skilled nursing facility, hospice care, and certain home health services. It covers services received within a facility rather than ongoing medical needs in a home environment. Therefore, Medicare Part A generally does not cover durable medical equipment for use at home.

Any durable medical equipment provided under Part A typically is used during an inpatient stay, such as a hospital bed within a hospital room. This equipment is considered part of the facility’s overall service and not a separate benefit for personal home use. Once a patient is discharged from the inpatient facility, Medicare Part A coverage for that specific equipment ends. If a long-term care facility is considered a beneficiary’s home, Medicare may cover approved DME in that setting.

Medicare Part B Coverage for DME

Medicare Part B is the primary component of Original Medicare covering medically necessary Durable Medical Equipment for use in a beneficiary’s home. The equipment must be medically necessary, and a doctor or other healthcare provider must prescribe it to treat an illness or injury. A physician’s written order or prescription for the specific DME is a requirement.

The equipment must be obtained from a Medicare-approved supplier that accepts assignment. Accepting assignment means the supplier agrees to accept the Medicare-approved amount as full payment for the item, billing Medicare directly. This helps ensure beneficiaries are only responsible for their coinsurance and deductible. After meeting the annual Part B deductible, beneficiaries typically pay 20% of the Medicare-approved amount for the DME. Medicare covers the remaining 80%.

Medicare may cover the rental or purchase of DME, depending on the specific type of equipment and applicable rules. For many items, such as certain manual and power wheelchairs, initial rental is common. After 13 months of continuous rental payments for some items, beneficiaries are generally considered the owner of the equipment. Medicare allows a choice between renting or buying for certain items, including some power wheelchairs and items costing less than $150. For oxygen equipment, different rules apply, with reimbursement typically limited to 36 monthly rental payments.

Examples of DME covered under Part B include oxygen equipment, wheelchairs, hospital beds, continuous positive airway pressure (CPAP) devices, and walkers. Additionally, certain diabetes supplies like blood sugar monitors and test strips, as well as nebulizers and their medications, are also covered. Medicare generally covers the most basic form of equipment needed for a condition.

Steps to Obtain Covered DME

Obtaining durable medical equipment covered by Medicare begins with a visit to a doctor or other healthcare provider. During this visit, individuals should discuss their medical needs and obtain a prescription or written order for the specific DME. The doctor’s order is the initial step, documenting the medical necessity of the equipment.

After securing the necessary prescription, the next step involves finding a Medicare-approved DME supplier. Beneficiaries can search for approved suppliers through the Medicare website or ask their doctor for recommendations. Confirm that the chosen supplier accepts Medicare assignment, which helps manage out-of-pocket costs.

Before receiving the equipment, individuals should confirm with the supplier that the specific DME is covered for their situation. The supplier will often handle the submission of required documentation to Medicare. Once approved, the equipment can be delivered, and the supplier may provide necessary setup or training for its proper use.

Beneficiaries should carefully review their Explanation of Benefits (EOB) from Medicare and any bills received from the supplier to ensure accuracy. If coverage is denied, individuals have the right to appeal the decision. Information on the appeals process is provided in the denial letter or by contacting Medicare directly.