Every plan covers DME differently. It might be free or you might be responsible for some of the cost, usually through coinsurance
Different medical equipment may have different coverage restrictions
Durable medical equipment (DME) is a device or tool that is medically necessary for a patient. The equipment must be vital to your daily life, like an oxygen tank or blood sugar tests for diabetics, and not just for your comfort — like a humidifier or air purifier.
DME helps you with your illness, injury, or condition, and does not necessarily have to be used for an extended period of time. It might be needed in more temporary circumstances — for example, if you need crutches while you’re recovering from a major surgery.
Since DME is intended for home use, vehicles and car customizations are not covered. Durable medical equipment is also not meant for personal care and conveniece, so unfortunately home improvements like ramps and grab bars are excluded as well. Unless the insurance company decides these improvements are medically necessary in your circumstances, they will not be covered as DME or through another part of your health insurance.
Medicare and Medicaid both offer DME coverage. Private health insurance plans are not required to cover DME, but many do, so you’ll need to check with your plan provider. If your coverage does include it, you will typically need to get a prescription from your doctor. Your health plan will detail whether you can rent or buy DME and how exactly the costs are covered. Coverage benefits may also vary based on the medical equipment.
Examples of DME
Insurance providers have different lists of DME so take a look at the details of your policy.
Durable medical equipment typically includes the following:
Blood sugar monitors or test strips
Crutches and canes
Patient lift system
Wheelchairs (automatic and manual)
How is DME covered?
The insurance company will determine what is considered durable medical equipment and outline what you need to do to get it. Typically, DME eligibility requires prior authorization from a provider if the medical equipment costs over a certain amount. You will need to get a written notice or prescription from your primary care physician or other medical professional.
Next, you will look for an approved DME supplier. (Your insurance company website usually has a searchable database or list of approved suppliers, just like it does with physicians.) Depending on your plan structure, you might see both in- and out-of-network DME suppliers, which might be priced differently depending on the type of insurance plan you have.
Your health insurance company might also request that you get your DME from a preferred brand. A non-preferred brand might be more expensive or not covered by your insurer.
Rental vs purchase
Your insurance company might give you an option to rent or buy depending on the device. For example, an arm sling or neck brace might have to be purchased, but you might be able to rent a hospital bed.
When deciding whether to rent or buy DME, you might consider how long you’ll need it and how often you might need to repair or replace it (more on that next).
Cost of DME
Your health plan has rules on how durable medical equipment is covered. Some health plans might not charge you and cover the cost of in-network DME. With other plans you might be responsible for coinsurance, or a percentage of the costs, whether rented or purchased.
For example, let’s say your plan has a 80/20 coinsurance split for durable medical devices from an in-network supplier. That means you will pay 20% of the monthly rental or purchase and health insurance will cover the remaining 80% of the bill.
Different medical equipment may have different coverage restrictions. For example, in one plan you might not have the same benefits with manual wheelchairs versus power wheelchairs, but another plan may cover all DME the same way. Every insurance plan covers DME differently so make sure you understand the costs ahead of time.
DME maintenance, repair and replacement
Some medical equipment like monitoring services or power wheelchairs may need to be calibrated or repaired. There is also the chance something may break.
Your health plan will have different rules for how repairs and replacements are covered and how they are priced. Typically if you rent your DME, you are already paying fees that factor in the cost of maintenance. That means you might be able to get a repair or replacement at little to no extra cost.