What Durable Medical Equipment (DME) is Not Covered by Medicare?
Medicare covers durable medical equipment (DME) and supplies as long as the items meet Medicare’s strict definition for DME and the equipment is medically necessary. Medicare does not cover durable medical equipment used outside the home or, equipment used to modify your home.
DME Not Covered By Medicare
Original Medicare does not cover any durable medical equipment (DME) that does not meet strict criteria set by the U.S. Centers for Medicare & Medicaid Services.
- Must be deemed medically necessary by a doctor or other qualified health care provider
- Should have a usable life of at least three years
- Must be durable — able to withstand repeated use
- Should not be useful to someone who is not sick or injured
- Must be used in your home
For example, a powered wheelchair or scooter you need only outside your home is not covered by Original Medicare. But if your doctor determines that it is medically necessary that you have one to get around your home, Medicare will cover it.
Typical DME that Medicare will cover includes hospital beds, wheelchairs, walkers and home oxygen equipment.
Medicare will not cover any disposable supplies — unless the supplies are used in conjunction with recognized durable medical equipment that is used inside the home. For example, Medicare will cover diabetes test strips (used with testing equipment), but not supplies like adult diapers.
Medicaid vs. Medicare DME Coverage
If you qualify for Medicaid, the home use limitation on durable medical equipment and supplies does not apply.
Medicaid will cover DME and supplies that are needed for you to function in your community, not just in your home.
Medicaid will also cover some supplies not used in conjunction with covered DME — as long as the supplies are needed in order for you to function in your community. This could include disposable supplies such as adult diapers.
To qualify for Medicaid, you have to meet requirements for limited income and financial resources, but you can be enrolled in both Medicare and Medicaid at the same time. When you qualify for both programs it is called dual eligibility.
What Is Not Considered Durable Medical Equipment by Medicare?
The list of durable medical equipment that Medicare does not cover is lengthy. If you wonder whether a specific item is covered, you should check with Medicare or your plan’s administrator.
Typically, anything that fails to meet Medicare’s five criteria for durable medical equipment is not covered.
- Devices or equipment specifically designed to help you outside your home
- Disposable items not used with approved durable medical equipment
- Equipment or devices that are not deemed medically necessary by your doctor or other qualified health care provider
- Items primarily intended to make you more comfortable or to make life more convenient
- Items that are not suitable for use in a home
Notably, the modifications you make to your home as you age and become less mobile or in the event that you become disabled, are not considered DME under Medicare’s rules and, therefore, are not covered.
- Air conditioners
- Bathtub seats or lifts
- Catheters (may sometimes be covered as prosthetic devices if you have a permanent condition requiring them)
- Compression leggings
- Contact lenses
- Grab bars
- Hearing aids
- Incontinence pads
- Oscillating beds
- Paraffin bath units
- Stairway elevators
- Surgical face masks
- Toilet seats
- Wheelchair ramps or widened doors for wheelchair access
Medicare will not cover any DME if your doctor and your DME supplier are not enrolled in Medicare. If they are not Medicare-enrolled, Medicare will not pay the claims they file, and you may have to pay the full price of any equipment you receive.
Medicare Advantage vs. Original Medicare for Medical Items
Medicare Advantage plans are sold by private insurers that contract with Medicare. There are some differences between how Original Medicare — Medicare Part A and Part B — and Medicare Advantage plans treat durable medical equipment.
|ACTION||ORIGINAL MEDICARE||MEDICARE ADVANTAGE|
|Find a DME supplier||You may have to use competitive bidding suppliers to qualify for coverage in certain regions.||Plans use their own, in-network suppliers. Contact your plan administrator to make sure you are using a supplier in your network to avoid surprise out-of-pocket costs.|
|Get DME approval||You may need prior authorization from Medicare before it will pay for some devices such as expensive wheelchairs or mobility devices. Check with Medicare if your doctor isn’t sure.||Many DME items require prior authorization from your plan. Contact your plan’s administrator to confirm that it will pay for the DME beforehand.|
|Your costs for DME||Medicare Part B pays 80 percent of the cost after your deductible. You are responsible for the deductible and 20 percent of the Medicare-approved cost.||Your Medicare Advantage plan sets its own copayment amount. This varies from plan to plan. Check with your plan’s administrator to find out how much you will be responsible for.|
Medicare Advantage plans are required by law to cover everything that Original Medicare covers. But Medicare Advantage plans may also offer benefits that Original Medicare does not, such as coverage for certain items that Original Medicare does not consider to be durable medical equipment.
- Contact lenses
- Hearing aids
If these and other potential benefits appeal to you or your health situation, you should ask about additional benefits when shopping for a Medicare Advantage plan.
4 Cited Research Articles
- U.S. Centers for Medicare & Medicaid Services. (2020, August). Medicare Coverage of Durable Medical Equipment & Other Devices. Retrieved from https://www.medicare.gov/Pubs/pdf/11045-medicare-coverage-of-dme.pdf
- Burke, G. and Chan, D. (2018, May). Understanding Durable Medical Equipment. Retrieved from https://ncler.acl.gov/pdf/Understanding%20DME%20Issue%20Brief.pdf
- Washington State Office of the Insurance Commissioner. (n.d.). Will Medicare Pay for My Medical Equipment (Like Blood Sugar Monitors and Wheelchairs)? Retrieved from https://www.insurance.wa.gov/will-medicare-pay-my-medical-equipment-blood-sugar-monitors-and-wheelchairs
- U.S. Centers for Medicare & Medicaid Services. (n.d.). Durable Medical Equipment (DME) Coverage. Retrieved from https://www.medicare.gov/coverage/durable-medical-equipment-dme-coverage