What Is an HME Insurance Plan and What Does It Cover?
Demystify HME insurance. Learn about coverage, costs, and finding the right plan for your home medical equipment needs.
Home Medical Equipment (HME) plays a role in managing health conditions and facilitating recovery within a home setting. These devices are crucial for individuals with chronic illnesses, disabilities, or those recovering from injuries and surgeries. The costs can be substantial, making insurance coverage a practical consideration.
Understanding Home Medical Equipment Insurance
Home Medical Equipment insurance is a specific component of health insurance coverage designed to help individuals afford necessary medical devices and supplies used at home. This coverage extends to durable medical equipment (DME), prosthetics, orthotics, and various medical supplies. Its purpose is to ensure patients can access essential tools for managing their health outside a clinical environment.
This insurance differs from general health insurance, which covers medical services, doctor visits, and prescription medications. HME insurance focuses on the equipment itself, making these items accessible and financially manageable. A requirement for coverage is “medical necessity,” meaning the equipment must be essential for diagnosing, treating, or managing an illness, injury, or condition, and must meet accepted medical standards.
Commonly Covered HME Categories
HME insurance covers a wide array of equipment. Mobility aids, such as wheelchairs, walkers, canes, and crutches, are covered items that assist individuals with movement limitations. Respiratory equipment, including oxygen concentrators, nebulizers, and Continuous Positive Airway Pressure (CPAP) machines, helps patients with breathing difficulties.
Other covered items include hospital beds and specialized mattresses. Medical supplies like blood sugar monitors, test strips, and lancets for diabetes management, as well as infusion pumps, are included. Prosthetics and orthotics, which replace or support body parts, also fall under HME coverage. Durable medical equipment must withstand repeated use, serve a medical purpose, be suitable for home use, and last at least three years.
Navigating Coverage and Costs
Understanding HME insurance costs involves deductibles, co-payments, and co-insurance. A deductible is the amount an individual pays before the insurance plan covers costs. After the deductible is met, co-payments are fixed amounts for a service, while co-insurance is a percentage of the cost the patient is responsible for.
Prior authorization is often required before obtaining certain HME items. This process involves the insurance company reviewing and approving the equipment’s medical necessity. Many insurance plans, including Medicare, may cover equipment rental before purchase, or offer a choice between renting and buying based on cost and medical needs. A doctor’s prescription is required for coverage, establishing medical necessity.
Sources of HME Coverage
Several types of insurance providers offer HME coverage. Medicare Part B is a source of HME coverage for eligible individuals. Medicare Part B covers medically necessary durable medical equipment when prescribed by a Medicare-enrolled doctor for use in the home, with beneficiaries paying 20% after meeting their annual Part B deductible. Medicare Advantage plans are required to cover at least what Original Medicare covers.
Medicaid also provides HME coverage, though the specific benefits and eligibility criteria can vary by state due to the joint federal and state nature of the program. Private health insurance plans, whether employer-sponsored or purchased independently, often include HME benefits. Individuals with private insurance should carefully review their policy documents or contact their provider to understand the specifics of their coverage, including any limitations or requirements. Other potential sources of coverage include TRICARE, which covers medically necessary DME for military service members, retirees, and their families, and Veterans Affairs (VA) benefits, which can provide free durable medical equipment to eligible veterans receiving VA care. It is always advisable to confirm specific coverage details directly with the insurance provider, as policies and rules can differ considerably.