To get Medicare to cover your durable medical equipment (DME), your Medicare-enrolled provider must sign an order or fill out a prescription or certificate that explains why you need the item. This means your doctor believes the item is medical necessary for you. Medicare will generally only pay for the most basic form of the equipment that you need.
Once you have the doctor’s order or prescription, you can take it to any Medicare-enrolled supplier. If you receive care from a certified home health agency (CHHA), the agency will provide these items to you. Medicare will pay 80 percent of its approved amount (after you meet your Part B deductible) and you or your supplemental insurance pay the 20 percent balance. You can save a lot of money by going to a supplier who also accepts Medicare assignment. Accepting Medicare assignment means the supplier takes Medicare’s approved amount for an item as payment in full.
Starting January 1, 2011, if you live in, or are visiting certain regions in certain states when you need DME you must use a contract supplier in order for Medicare to cover certain DME. These states are NC, SC, OH, KY, IN, TX, MO, KS, FL, PA and CA. If you do not use a contract supplier, Medicare will not pay for your DME. Contact 800-MEDICARE for more information about who the contract supplier is in your region.
If you are going to use a supplier who does not contract with Medicare in one of the states above, the supplier must let you know that they are not a contract supplier and that Medicare will not pay. The supplier should have you sign an Advanced Beneficiary Notice (ABN). This notice states that you are aware that Medicare will not cover the DME and you will be responsible for the full cost. If the supplier does not have you sign an ABN, you are not responsible for the full cost of your DME.
Medicare will pay for only one item or piece of equipment for a particular condition at any one time.
If your condition changes and you need a different kind of equipment, Medicare will allow you to switch your equipment. To make a switch your doctor must fill out a new order or prescription. If you are in a Medicare Advantage plan (like an HMO or PPO), you must follow the plan’s rules for getting DME. These rules may be different from the rules in Original Medicare. Medicare Advantage plan rules for DME often include getting prior authorization for equipment from the plan and using a doctor and DME supplier in the plan’s network. Call your plan to find out what you must do to get DME covered.
DME benefits are administered through the DME MAC (Durable Medical Equipment Medicare Administrative Contractor) in your area. If you have any questions about whether or not a piece of equipment will be covered or who the contract suppliers are if you live in certain regions in the country, contact 800-Medicare for more information.
Additional coverage rules apply for Medicare coverage of wheelchairs and scooters. Please click here for more information.