If you work in medical insurance for the senior market, then you’ve likely heard the term durable medical equipment, often referred to by its acronym DME, before. But what exactly is DME, and what is its relevance to Medicare coverage?
In this blog post, the lead generation experts at Need-A-Lead discuss everything you need to know about DME, including which DME is covered by Original Medicare (Medicare Parts A and B). Be sure to check back on this blog frequently for even more information about Medicare coverage and other issues related to health insurance for seniors, and get in touch with the Need-A-Lead team today to request a free quote on your next lead generation campaign.
According to Title XIX for Medicaid:
The term “durable medical equipment” includes iron lungs, oxygen tents, Nebulizers, CPAP, catheters, hospital beds, and wheelchairs (which may include a power-operated vehicle that may be appropriately used as a wheelchair, but only where the use of such a vehicle is determined to be necessary on the basis of the individual’s medical and physical condition and the vehicle meets such safety requirements as the Secretary may prescribe) used in the patient’s home (including an institution used as his home other than an institution that meets the requirements of subsection (e)(1) of this section or section 1819(a)(1)), whether furnished on a rental basis or purchased, and includes blood-testing strips and blood glucose monitors for individuals with diabetes without regard to whether the individual has Type I or Type II diabetes or to the individual’s use of insulin (as determined under standards established by the Secretary in consultation with the appropriate organizations); except that such term does not include such equipment furnished by a supplier who has used, for the demonstration and use of specific equipment, an individual who has not met such minimum training standards as the Secretary may establish with respect to the demonstration and use of such specific equipment. With respect to a seat-lift chair, such term includes only the seat-lift mechanism and does not include the chair.
In layman’s terms, DME is reusable medical equipment that is used in the home.
Medicare Coverage of DME
Anyone who has Medicare Part B can get their DME covered, as long as a healthcare provider — such as a nurse practitioner, physician assistant, or clinical nurse specialist — has deemed the equipment medically necessary for use in the patient’s home. A hospital or nursing home providing the patient with Medicare-covered care doesn’t qualify as the patient’s “home” in this situation. A long-term care facility, however, may qualify.
It is important to note that Medicare only covers DME if you get it from a supplier enrolled in Medicare, meaning that that supplier has been approved by Medicare and has a Medicare supplier number.
Medicare Advantage Coverage of DME
Since Medicare Advantage plans (sometimes referred to as Medicare Part C), must cover the same medically necessary items and services as Original Medicare, individuals with Medicare Advantage plans will also have their DME covered. Specific costs, however, will vary according to which Medicare Advantage plan the patient has. If an individual’s Medicare Advantage plan won’t cover a DME that the patient believes that they need, they may appeal their plan’s denial of coverage and get an independent review of their request.
What DME Is Covered?
Original Medicare and Medicare Advantage cover medically necessary DME including, but not limited to, the following:
- Pressure-reducing beds, mattresses, and mattress overlays used to prevent bedsores
- Blood sugar monitors and test strips
- Canes (excluding white canes for the blind)
- Commode chairs
- Continuous passive motion (CPM) machines
- Hospital beds
- Infusion pumps and supplies
- Manual wheelchairs and power mobility devices, such as scooters (when needed for use inside the homes)
- Oxygen equipment and accessories
- Patient lifts
- Sleep apnea and continuous positive airway pressure (CPAP) devices and accessories
- Suction pumps
- Traction equipment
What the Patient Pays
Generally, the patient must pay 20% of the Medicare-approved fee after they reach their Part B deductible for the year, with Medicare paying the remaining 80%. However, the amount the patient pays may vary because Medicare pays for different types of DME in different ways. For instance, patients may be able to rent or buy the equipment.
Prosthetic and Orthotic DME
Prosthetic and orthotic DME refers to artificial devices and body parts. Prosthetic and orthotic DME covered by Medicare include:
- Arm, leg, back, and neck braces
- Artificial limbs and eyes
- Breast prostheses and mastectomy bras
- Ostomy bags
- Urological supplies
- Therapeutic shoes or inserts for individuals with severe diabetic foot disease
Are Corrective Lenses Covered?
Prosthetic lenses in the form of cataract glasses (for aphakia or absence of the lens of the eye), conventional glasses or contact lenses after surgery with insertion of an intraocular lens, and intraocular lenses are all considered DME, and are covered by Medicare.
Buying vs. Renting DME
Medicare-enrolled supplies are aware of which kinds of DME patients may buy, and which kinds they may rent. Medicare pays for most DME on a rental basis, and generally only buys inexpensive or routinely bought items, such as canes, walkers, and blood sugar monitors. If the patient owns their own Medicare-covered DME, Medicare may cover up to 80% of any required repairs and replacement parts
What if the Patient’s Needs Change?
There are times when patients may need to tell their supplier about changes in their life, and how they will affect their DME. These situations include, but are not limited to:
- Changing insurance companies
- Changing doctors
- Entering a hospital
- Enter a nursing home
- Changing phone numbers or other contact information
If the patient plans on traveling, and requires a portable oxygen concentrator (POC), they should let their supplier know weeks in advance. It is important to note that oxygen equipment suppliers are not required to give patients an airline-approved portable oxygen concentrator (POC), and, in fact, Medicare won’t pay for any oxygen related to air travel. The patient, may, however, be able to rent a POC from their supplier as long as they give them enough notice. Rentals are also available through online companies that work with most airlines.
Get Medicare Advantage & Medigap Leads from Need-a-Lead
If you’re an insurance agent, insurance company, or IMO looking to find 100% exclusive senior health insurance leads, turn to Need-A-Lead. We have more than three decades of experience in running lead generation campaigns for insurance agents working with the senior market. In addition to Medicare Advantage and Medicare Supplement (Medigap) leads, we can also provide you with final expense leads, annuity leads, long-term care leads, and turning 65 leads. To get started with your lead generation campaign, request a free quote today.