UPDATED: May 26, 2020
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Those going through a medical condition requiring tools and equipment for at-home use or preparing for recovery assistance after surgery may be curious as to what insurance covers. While this does vary based on the insurance company, there are a few best practices that most, especially the best insurance companies, follow.
In this guide about insurance and Durable Medical Equipment, we’ll cover what Durable Medical Equipment (DME) is and isn’t, what insurance providers will cover of this equipment, the purchasing process, and what to do if insurance will not cover the costs.
What is Durable Medical Equipment (DME)?
Durable Medical Equipment is categorized as any medical equipment for home use that is reusable and for long-term use. This includes but is not limited to walkers, wheelchairs, commodes, and oxygen tanks.
DME should not be confused with Home Medical Supplies, which are items that are not reusable, such as commode liners, adult diapers, and other incontinence supplies.
To qualify as Durable Medical Equipment, the item must meet the following requirements:
- Must be recommended, prescribed, or ordered by a medical professional
- Must be primarily used for medical purposes
- Must be able to be used continuously
- Must be appropriate for home use
- Must not be used for individuals without an injury or disability
What DME items will insurance cover?
The answer to this question will always depend on your insurance carrier, your insurance package, and your health condition.
Insurance may cover the entire expense of your DME, partially with a copay, or none of the cost.
It’s always best to talk with your doctor and insurance provider when deciding on any DME item.
Where can I purchase DME items?
The purchasing process for DME items can vary depending on your insurance, as well as what may be most convenient for you. One commonly used option is to purchase DME items directly through your doctor, and they will bill your insurance.
Most DME items can be purchased over-the-counter online or at your local store. However, some items may require a prescription from your doctor.
Online marketplaces such as Amazon carry a wide selection of Durable Medical Equipment, many of which can be covered by insurance. Amazon and other marketplaces will let you know if an item is FSA or HSA eligible and allow payment with your FSA/HSA card at checkout.
Before purchasing DME, ask your doctor for their recommendations and do some online research for the best choice to meet your needs.
Always check with your insurance to see if they’ll cover a specific item.
If you are being discharged directly from the hospital, you may work with the nurse or a social worker to select the proper DME item. If you need the item immediately before leaving the hospital, then you may have to get it directly through the hospital to ensure your safety and wellbeing.
You’ll typically see the charge on your insurance statement as well as what was and wasn’t covered.
How is DME covered?
This will vary depending on your insurance provider. However, they will determine what types of Durable Medical Equipment they’ll cover based on your package, ailment, and what the doctor recommends. The insurance provider may require authorization from your doctor if the cost is over a certain amount.
Some providers will have a list of approved DME suppliers and brands for you to choose from. These lists show for which of the suppliers and brands they’ll cover part of the full costs.
Another option your insurance provider may give you is the option to buy or rent the DME item. If the item you’re using is only temporary (such as a knee scooter or wheelchair for a foot/leg injury), then it may be cheaper to rent instead of buy.
What payment options are available?
There are various payment options when trying to cover the costs for DME. They include:
- Medicare – This type of coverage typically covers 80 percent of DME items as long as they’re deemed necessary, and you would only have to cover 20 percent of the cost. However, Medicare coverage is known for not including specific home modification items such as grab bars and safety ramps.
- Medicaid – This coverage is for those that are on a limited income. An advantage of Medicaid is it covers more DME items than Medicare (grab bars and safety ramps are often included in coverage). It usually covers more substantial portions of the cost as well.
- Veteran Benefits – If you are a veteran, you may be eligible to have your cost wholly covered. The government-run Veterans Administration (VA) can be a great source of information and support when trying to cover DME costs.
- Private Insurance – This coverage is typically excellent in terms of DME coverage. They even may cover some home safety modifications when needed. A downside is private insurance providers usually don’t cover home medical supplies, but it’s always best to inquire.
What if my insurance won’t cover the DME cost?
This can be a terrifying and frustrating scenario to be in, especially if the cost is rather high. If you find yourself in this situation, you have three options:
- Appeal the claim – Appealing to an insurance provider is usually pretty straightforward. It may require you to revisit your primary care provider so they can give the provider their professional opinion as backing. Another possibility is that the denial was made by mistake.
- Sue the insurance provider – This option can take up a lot of time and money, which may not be worth it. However, some lawyers work on a “contingency fee” basis. Under these conditions, the lawyer does not take any money unless they win and they usually receive a portion of the settlement money.
- Pay the cost out of pocket – This is an easy option if the DME item is lower in price, and you can afford the cost. It may also be easier to get a used DME item if applicable. There are many sellers online that offer low-cost and competitive pricing.
Making sure your insurance covers your Durable Medical Equipment is vital to avoid added costs.
Ask both your insurance provider and doctor any questions you have. Be sure to gain a thorough understanding of what is and isn’t covered.
Do your own research, too, and try to reach out to anyone that may have found themselves in a similar position. Make sure you understand health insurance terms and definitions so you’re better prepared to make the right decisions.
Brandon Landgraf is a digital marketing manager and content creator for Carex Health Brands, a health and wellness brand whose mission is to improve the lives of others. He enjoys writing content that empowers others to live better, be healthier, and lead happier lifestyles.