Medicare should pay for DME, except wheelchairs, if you follow two basic steps explained below. There is a different process when you want Medicare to pay for your manual or power wheelchair or scooter.
1. Start with your doctor or primary care provider. If you think you need DME, ask your doctor about it. Or, your doctor may be the one to recommend DME to you. For example, when you are leaving the hospital, the doctor who treated you in the hospital may order equipment for your use when you return home. Or, during a doctor’s office visit, the doctor may suggest DME to help you function better in the home.
Medicare will only pay for your DME if your doctor or other primary care provider signs an order, prescription or certificate that states that you need the DME to help a medical condition or injury. Your doctor must also confirm that you will use the equipment in the home. Starting July 1, 2013, you must have an office visit with your doctor or other health care professional before Medicare will cover your DME. The visit must deal with the reasons you need the DME and happen no more than 6 months before the date of your equipment order. The order must include a statement from your doctor confirming the required office visit took place.
2. Use the Right Kind of Supplier. Once you have the doctor’s order or prescription, you must take it to the right supplier to get coverage. Be sure only to use suppliers with approval from Original Medicare or your Medicare Advantage Plan.
If you have Original Medicare, the type of supplier Medicare has approved for you will depend on how Medicare pays for equipment in your area and the kind of DME you need. In many areas, called competitive bidding regions, Medicare will usually only pay for most DME from a select group of suppliers known as contract suppliers. In other areas, you can use any supplier that has signed up to bill Medicare. Pay special attention if you need diabetic supplies.
Starting July 1, 2013, in all regions of the United States, a competitive bidding program will apply to all diabetic supplies gotten through mail order. This means that you must use contract suppliers if you get your diabetic supplies through mail order. Mail order can mean diabetes supplies that are sent to you by a supplier in the mail, or supplies that are delivered to your home by a pharmacy. If you get your diabetic supplies from a local pharmacy, you should make sure you use a pharmacy that accepts Medicare assignment.
Call 1-800-MEDICARE or go www.medicare.gov/supplier to get a list of suppliers Medicare has approved for you. Remember to find out whether the competitive bidding program affects you since it decides the suppliers you can use and the amount you will pay.
Also, if you live in or plan to travel to a competitive bidding demonstration area and (need DME that is included in the demonstration), make sure you are informed about the types of suppliers you must use and your costs for DME.
If you live in an area that is not part of the competitive bidding demonstration, you may need to rely on different kinds of suppliers.
If you have a Medicare Advantage Plan (like an HMO or PPO), you must follow the plan’s rules for getting DME.
- The plan may require you get its approval before you get your DME.
- It may also ask you to use suppliers in the plan’s network. You may get little or no coverage if you use suppliers outside of the plan’s network.
- Your plan may also have a list of preferred brands of DME. These brands will cost you the least while you are a plan member. Make sure you use preferred brands when possible to limit your costs.
Call your plan to find out what you must do to get DME covered. People in Medicare Advantage Plans will not be affected by the competitive bidding demonstration.