Medicare Part B covers durable medical equipment (DME). After you meet your annual Part B deductible, you pay 20% of the Medicare-approved amount, and Part B picks up the remaining 80%. This applies whether you have Original Medicare or a Medicare Advantage plan, though Advantage plans may have their own network rules and cost-sharing structures.
What Counts as Durable Medical Equipment
Not everything medical qualifies as DME under Medicare’s definition. To be covered, an item must be designed for repeated use, serve a medical purpose, be appropriate for use in the home, and be expected to last at least three years. A doctor also needs to confirm the equipment is medically necessary for your condition.
Common covered items include wheelchairs and power scooters, hospital beds, oxygen equipment, CPAP machines, walkers, canes, crutches, blood sugar monitors and test strips, nebulizers, and patient lifts. Prosthetic devices and certain orthotic braces also fall under Part B coverage.
Items Medicare Does Not Cover
Several categories of equipment that seem medical are excluded. Home modifications like ramps, widened doorways, grab bars, and stairway elevators are not covered, even if they help you use medical equipment. Bathtub seats, raised toilet seats, and air conditioners are also excluded.
Disposable supplies that get thrown away after a single use generally aren’t covered either. This includes incontinence pads, surgical face masks, and compression stockings. Equipment designed for hospital or skilled nursing facility use, such as paraffin bath units and oscillating beds, won’t be covered for home use.
Renting vs. Buying Equipment
Medicare handles different types of equipment differently when it comes to renting and purchasing. For CPAP machines, hospital beds, and pressure-reducing mattresses, you rent the equipment month by month and own it outright after 13 months of rental payments. During that rental period, your supplier is responsible for any repairs at no extra charge.
Oxygen equipment works on a longer timeline. Medicare makes rental payments for 36 months. After that, payments stop, but your supplier must continue providing the oxygen equipment, accessories, and supplies at no rental charge through the end of the equipment’s useful lifetime, which is generally five years from your original delivery date. Enteral infusion pumps follow a similar model: after 15 months of continuous rental, your supplier must keep providing the pump as long as it’s medically necessary.
Once you own a piece of equipment, you can use any Medicare-approved supplier for repairs or replacement parts. But if you need to fully replace the equipment, you’ll need to go through a Medicare contract supplier for coverage to apply.
What You’ll Pay Out of Pocket
Your cost for DME follows the same structure as most Part B services. You first pay your annual Part B deductible, then 20% of the Medicare-approved amount for each item. The “Medicare-approved amount” is a set price that Medicare determines, not necessarily what the supplier charges.
Your costs can vary depending on whether your supplier accepts “assignment.” A supplier that accepts assignment agrees to charge only the Medicare-approved amount. You pay your 20% coinsurance based on that figure, and nothing more. A supplier that doesn’t accept assignment can charge up to 15% above the Medicare-approved amount, which means your out-of-pocket share increases. Always confirm whether a supplier accepts assignment before placing an order.
Getting Your Equipment Covered
Medicare won’t cover DME without a doctor’s order. Your physician needs to document why the equipment is medically necessary for your specific condition, and for certain items, a formal certificate of medical necessity is required. This paperwork goes from your doctor to the equipment supplier, who then bills Medicare.
You also need to get your equipment from a Medicare-enrolled supplier. Using a supplier that isn’t enrolled in Medicare means you’ll likely pay the full cost yourself. If you have a Medicare Advantage plan, check whether your plan requires you to use specific in-network suppliers, as going out of network could mean higher costs or no coverage at all.
How Medicare Sets DME Prices
Medicare uses a competitive bidding program to set prices for certain DME items in specific geographic areas. As of January 2024, the program is in a temporary gap period while CMS works on establishing the next round of bidding. During this gap, Medicare adjusts payment rates in former competitive bidding areas based on previous prices updated for inflation using the Consumer Price Index.
What this means practically is that the price Medicare approves for the same piece of equipment can differ depending on where you live. Your 20% coinsurance is always based on whatever Medicare-approved amount applies in your area, so two people with the same wheelchair could pay slightly different amounts depending on their location.