Durable Medical Equipment (DME) Insurance

Doctor Naomi Gallant
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Senior Care Consultant

Dr Naomi Gallant is an Occupational Therapist with the King’s College Hospital NHS Foundation Trust, specialising in the care of people with dementia. She holds a Clinical Academic PhD in Dementia Care from the University of Southampton.  Learn more about our team.

DME or HME are terms you will encounter if you have to use medical supplies or equipment over a long period. They are short for Durable Medical Equipment and Home Medical Equipment.

As people age, they rely on medical equipment and supplies. The demand for DME soars when you couple up the rising populations of seniors with the increasing number of people suffering from chronic illnesses.

A report of research done in 2019 highlighted a growing market for DME. The report cited increasing elderly populations, road accidents, and chronic diseases fueling the growth.

DME is a term used by Medicare (part B) and other medical insurers to cover equipment that can withstand repeated use, such as hospital beds. We will look extensively at what DME stands for and its insurance coverage.

Table of Contents

What is DME?

DME stands for Durable Medical Equipment. Home Medical Equipment (HME) is another way a healthcare provider may refer to durable medical equipment.

Durable Medical Equipment (DME) is a term used by Medicare to describe medical equipment and devices that are durable enough to be used multiple times for an extended period.

They also require little or no maintenance and are not easily damaged during use. Durable medical equipment is generally considered designed for day-to-day use or regular wear.

One of the benefits of durable medical equipment is that it can help people stay active and independent. In some cases, it can even help them continue living at home instead of going to a nursing home or other care facility.

What Qualifies as DME?

When most people think of durable medical equipment, they picture wheelchairs and hospital beds. However, a wide range of items can be classified as durable medical equipment.

Medical Insurance providers may have varying lists of what is covered under DME. You should always check to see what your insurance covers to avoid issues when you need them.

There are guidelines provided by Medicare (part B) to qualify items as durable medical equipment. Medicaid will cover medical equipment that’s medically necessary and cost-effective, with the state Medicaid program defining what items are covered. The criteria for this vary from one state to another, but it is generally similar to Medicare’s definition of durable medical equipment.

Here are the general guidelines for medical equipment to qualify as DME:

  • Durability (it should withstand repeated use)
  • Serve a medical purpose
  • Prescribed by a health care provider
  • Used at home
  • Not valuable for healthy people(people without a disability or injury)

Before we go further, there is something we need to highlight. As an alternative to a prescription, individuals can prepare a Justification Statement of Medical Necessity, which describes the condition and why they require home medical equipment or supplies. A medical officer will review the letter, and Medicare or Medicaid will cover your DME.

The medicare interactive website is an excellent resource for learning more about their options and benefits. It has clear explanations of how different things work and helpful tools that you can use before applying for Medicaid services or coverage of Medicare Part B monthly premiums. Useful to know if you’re planning on renting a hospital bed, for example.

That being said, many DME items fall under this category/department since people rely on them in their daily activities. They include;

  • Wheelchairs
  • walkers
  • Kidney machines
  • Diabetes self-testing equipment(Diabetes supplies)
  • Nebulizers and nebulizer medications
  • Oxygen tanks
  • home infusion pumps
  • Hospital beds and other hospital bed equipment
  • Patient lifts
  • Commode chairs
  • Crutches
  • Oxygen equipment
  • and many more
Examples of durable medical equipment

What Equipment is not Qualified as Durable Medical Equipment?

Some pieces of equipment are not considered durable medical equipment. This means they are not covered under the same benefits as durable medical equipment.

Sometimes an item qualifies as durable medical equipment but not under Medicare (DME) coverage. Maybe the item is not considered medically necessary even though you might find it useful.

Generally, any item that fails to meet the durable medical equipment guidelines is excluded from insurance coverage. The items tend to have the following description:

  • One-use or disposable that are not used with DME
  • It does not serve a medical necessity or purpose
  • Used to make life more convenient
  • Inappropriate for home use

Besides items that fit such description, any modifications made in your home to make life easier as you age or battle long-term illnesses are not covered by Medicaid programs or Medicare.

Here is a shortlist of items that are not considered to be durable medical equipment:

  • Bathtub lifts or seats
  • Toilet seats
  • Contact lenses
  • Incontinence pads
  • Stairway elevators
  • Home modifications such as widened doors or ramps
  • Air conditioners
  • Grab Bars

As with many things in life, there are always exceptions to the rule. Medicaid may cover the cost of some medical equipment that Medicare will not, and vice versa is also true. It doesn’t hurt to check your options if you want to find insurance coverage for a specific piece or size of equipment.

Visit this website when you want to find out what Medicare covers. If you’re wondering whether your Medicare or Medicaid plan covers something and can’t find an answer on their website – don’t worry!

The State Health Insurance Assistance Program (SHIP) offers advice about Medicaid programs and Medicare. The SHIP is an organization that provides information for people who need Medicaid or Medicare coverage of DME can help you find out more.  size

Does Insurance Pay for Durable Medical Equipment?

Most people with insurance have some coverage for durable medical equipment, but the specifics of that coverage depend on the Medicare policy. Some policies will cover a certain amount of money each year for DME, while others may only cover specific types of equipment or supplies. It is essential to read through your policy carefully to understand what isn’t covered.

For instance, Medicare pays up to 80% of the approved amount of the home medical equipment. Of course, you need to clear all related deductibles before your original Medicare, Medicare Advantage plans, or other insurance come into play. Therefore, you may end up paying more than 20% of the approved price of durable medical equipment (DME).

If you need DME and your insurance doesn’t cover it, you may get help from Medicaid or Medicare. However, these programs often have waiting lists, so you may not be able to get the equipment you need right away. You can also try contacting private companies that provide DME, but they may charge more than the government programs.

In most cases, if you can’t get the home medical equipment you need through insurance or a government program, you’ll have to pay for it out of pocket. This can be expensive, so it’s essential to start planning for it as soon as you know you’ll need the equipment. You may be able to get a loan or a payment plan from the company that provides your DME, or you could try asking your doctor for a prescription that will help you get a discount.

No matter your situation, it’s essential to talk to your insurance company and find out what they will and won’t cover. That way, you can ensure you’re getting the best possible care.


DISCLAIMER: Readers should consult their doctors before making any decisions relating to a medical condition