With age, there comes a dependency. We may require assistive equipment to help us do things that were earlier easy, such as climbing stairs or standing up from a chair. The majority of older adults have never previously encountered this type of adaptive equipment, and navigating this new world of insurance and vendors can be overwhelming. That’s why you need to know about Durable Medical Equipment widely termed as (DME).
What Is Durable Medical Equipment?
Durable medical equipment is things that are most familiar as hospital beds, commodes, wheelchairs, items like that that are needed for a patient or client to help them function with their daily living. There are some things that we all see in the hospital that you can have at home. Some things you need to have and some things are just a convenience.
Not just for people who are old and aged, DME also fits all the below mentioned criteria:
How Is The Coverage Offered For DME?
DME is generally covered subject to the indications listed below:
- Durable Medical Equipment (DME) and orthotic benefits, including certain disposable supplies, enteral feedings and the following diabetic supplies and equipment: glucose monitors, insulin pumps, syringes, blood, and urine test strips and other diabetic supplies as deemed medically appropriate and necessary, for members with gestational, Type I or Type II diabetes. No more than a 90-day supply will be covered and dispensed at a time.
- Durable Medical Equipment and supplies must be obtained from or repaired by, HealthPartners approved vendors.
- Durable Medical Equipment and orthotics are limited by the following:
- All covered DME items should be the acceptable and standard model, considering the member’s medical condition. If a member requests an alternative item/part, which is safe and effective, HealthPartners may cover the cost up to the cost of the acceptable standard model.
- The total payment for DME equipment to address a need will not exceed the cost of the standard equipment or service that is effective and medically necessary.
- DME items will not be approved which are primarily educational in nature, or for hygiene, vocation, comfort, convenience, or recreation.
- Covered services and supplies are based on established medical policies, which are subject to periodic review and modification by the Medical or Dental Directors.
Who Pays For Durable Medical Equipment?
The answer to this question is “it depends”. Medicare, federal insurance available to individuals 65 and over, disabled individuals, or persons with permanent kidney failure, has two types of insurance, Medicare Part A and Medicare Part B. Durable medical equipment is only partially covered under Part A if the insurance beneficiary means the patient qualifies for the Home Health Benefit. This means that the patient must be incapable of leaving his/her residence, requires skilled nursing care and does not require only custodial care bathing, toileting, etc. If the patient does qualify for such benefits, then Medicare will cover 80% of the allowable amount for medically necessary durable medical equipment. Each state sets its own allowable amount for each item.
Under Medicare’s Part B, the co-pay is the same – 20 % of the allowable amount and any additional expense after that. However, the patient does not have to qualify for the Home Health Benefit. If the physician or the physical or occupational therapist considers it medically necessary, then the patient can acquire partial reimbursement for the walker.
Medicare, however, does not cover all types of durable medical equipment. Hearing aids are not covered, and usually, home adaptation items, such as lifts, grab bars for bathroom safety, and ramps are not covered either. However, this can vary by state.
Medicare does not generally cover disposable medical supplies, although there are some exceptions for patients with diabetes, ostomy patients, and patients with feeding tubes. What Medicare does cover, however, is severely limited. Ostomy supplies, for example, are limited to a certain number per month. A patient can appeal this limitation to receive additional items but is only through an involved process including re-approval by a doctor and Medicare.
Medicaid, a federal-state program that ensures populations with extremely low incomes, also varies state by state, but usually covers a wider selection of equipment and supplies and a larger portion of the expense if not all of it than Medicare. Medicaid, for example, covers the costs of hearing aids, as long as the patient fulfills certain criteria i.e., has a severe hearing loss, is visually impaired, or is cognitively impaired. Medicaid does not have the same strict limitations on duration of use and the number of supplies as does Medicare.
Some states have financial assistance programs for elderly or disabled individuals whose income exceeds Medicaid maximums – some of these programs include home modifications, though these programs vary state-to-state.
What Are Other Available Options?
While DME Providers offer products that are typically covered by Medicare and/or Medicaid and usually work with insurance to handle payment, many mobilities and accessibility equipment providers exist to fill the gap for equipment that is typically not covered by insurance, or for individuals who do not meet the qualifications for DME use.
Mobility and Accessibility Equipment providers sell residential-use products such as stairlifts, lift chairs, ramps, power scooters, and vertical platform lifts. This equipment provides assistance with common age-related issues, such as going up and downstairs to elevated homes or second-story living quarters, standing up, and walking long distances. Most of these companies sell directly to consumers, circumventing insurance altogether.
While out-of-pocket costs for such equipment may deter some shoppers, it is important to consider the alternative costs of moving into a new home, moving to an eldercare facility, or medical and emotional costs associated with a fall.
With costs of the most common durable medical equipment reaching upwards of $1,200, the need for payment by Medicare is substantial. This increased cost of medical equipment forces elderly persons to look to Medicare and the rules governing what is covered are often confusing and time-consuming. Find a durable medical equipment supplier and rely on their expertise, experience, and guidance.