What Durable Medical Equipment Your Insurance Will Actually Cover

What counts as durable medical equipment, and what your insurance might pay for

Durable medical equipment — or DME — is gear your doctor says you need to use at home for a medical reason, and it's built to last through repeated use. Wheelchairs, walkers, oxygen tanks, hospital beds, and continuous positive airway pressure (CPAP) machines are common examples. What your insurance covers depends on three things: whether your doctor has written an order for it, whether the item is on your plan's covered list, and whether you meet your plan's rules about renting versus buying.

Most insurance plans — including Medicare, Medicaid, and private plans — do cover DME, but the specifics change from plan to plan and sometimes from item to item. A wheelchair might be covered at 80 percent while a cane is covered at 100 percent. Some plans require you to rent first, then buy only if you'll need the item for longer than a set number of months. Others let you buy outright. The fastest way to know what your plan covers is to call the customer service number on your insurance card and ask specifically about the item you need.

Key Takeaways

• Your doctor must write an order for the equipment before your insurance will consider paying for it — a prescription alone is not enough.
• Coverage varies by plan, so calling your insurance company with the specific item name is the only way to know your out-of-pocket cost.
• Medicare covers DME at 80 percent after you meet your deductible, but only through suppliers enrolled in the Medicare program.
• Some plans require you to rent equipment for a certain period before they will pay to buy it, so ask about this rule before you rent.
• If your insurance denies coverage, you can ask your doctor to request a medical review, which takes one to two weeks.

How to get your insurance to cover the cost

Start by talking to the doctor who recommended the equipment. Tell them you need a written order — this is different from a prescription and is what insurance companies actually require. The order should include the specific item (for example, "manual wheelchair with elevating leg rests" rather than just "wheelchair"), the medical reason you need it, and how long your doctor thinks you'll need it.

Once you have the order, call your insurance company before you buy or rent anything. Have the order in front of you and ask: Is this item covered? What percentage do you pay, and what do I pay? Do I need to use a specific supplier? Is there a rental period before I can buy? Some insurance companies will tell you yes or no on the phone. Others will say they need to review the order and will call you back within a few days.

If your insurance says yes, ask for the name of an approved supplier in your area. Using an in-network supplier usually means lower out-of-pocket costs. If no suppliers are nearby, ask whether your insurance will cover an out-of-network supplier — many will, though you may pay more.

What Medicare covers and what you pay

Medicare Part B covers DME if your doctor orders it and you meet the medical need. After you pay your annual deductible (which changes each year), Medicare pays 80 percent of the approved amount, and you pay 20 percent. There is no upper limit on what Medicare will cover, but the item must come from a supplier enrolled in the Medicare program.

To find a Medicare-approved supplier, use the Medicare supplier directory at the official Medicare website, or call 1-800-MEDICARE. If you use a supplier who is not enrolled in Medicare, Medicare will not pay anything, and you will owe the full cost. This is why checking the supplier list before you order is important.

If you have a Medigap or Medicare Advantage plan in addition to Medicare Part B, that secondary plan may cover some or all of your 20 percent share. Call that plan to ask what they cover.

Medicaid coverage varies by state

Medicaid covers DME in all states, but the specific items covered and the rules about renting versus buying differ. Some states cover a wider range of items than others. Some require prior approval from the state before you order. Others let you order first and submit paperwork after.

Contact your state Medicaid office or your Medicaid managed care plan (if you are enrolled in one) to find out what DME is covered in your state and what paperwork you need. You can find your state Medicaid office through the official Medicaid website. Have your Medicaid number and the specific item name ready when you call.

Private insurance plans and employer plans

Private insurance and employer-sponsored plans each set their own DME coverage rules. Some cover a long list of items; others cover only the most common ones. Some require prior approval; others do not. The only way to know what your plan covers is to call the number on your insurance card.

When you call, have the item name and your doctor's order ready. Ask whether the plan covers it, what your cost share is (deductible, copay, or coinsurance), and whether you need to use an in-network supplier. If the plan says no, ask whether your doctor can request a medical review — sometimes a doctor's letter explaining medical necessity can change a denial.

Renting versus buying: what your plan requires

Some insurance plans require you to rent equipment first. If you rent for a certain number of months (often three to six), the plan will then pay to buy it. Other plans let you buy outright from the start. A few plans cover only rental, never purchase.

Ask your insurance company which rule applies to your item before you rent. If your plan requires renting first, make sure the rental agreement allows you to apply rental payments toward a purchase later — not all rental companies do this automatically. If your plan covers purchase but not rental, renting out of pocket first may cost you more in the long run.

What to do if your insurance says no

If your insurance denies coverage, you have options. First, ask your insurance company why they said no. Common reasons include: the item is not on their covered list, your doctor's order did not include enough medical detail, or the supplier is not in-network. Sometimes the reason is fixable.

If the reason is that your doctor's order lacked detail, ask your doctor to send an updated order with more information about your medical condition and why you specifically need this item. If the reason is the supplier, ask your insurance for a list of in-network suppliers and try ordering through one of them.

If neither of those works, ask your doctor to request a medical review. Your doctor writes a letter to your insurance company explaining why the equipment is medically necessary for you. The insurance company then has a set time (usually one to two weeks) to review the request and make a new decision. If they still say no, you can file a formal appeal, though this process takes longer.

Frequently Asked Questions

Do I need a prescription or an order from my doctor?

You need a written order, not just a prescription. An order includes the specific item, the medical reason, and how long you need it. Your doctor can write this order during an office visit or over the phone if they have seen you recently. Ask your doctor's office to send it directly to your insurance company or to the supplier.

Can I buy DME online or from a regular store instead of a medical supplier?

Insurance usually will not pay if you buy from a non-medical supplier, even if the item looks the same. Your insurance requires you to use an approved supplier so they can verify the item meets medical standards and that you actually need it. Buying elsewhere means you pay the full cost yourself.

What if I need the equipment right away but my insurance is still reviewing?

You can buy or rent the equipment while your insurance reviews, but keep all receipts. If your insurance approves coverage, you can submit the receipts for reimbursement. If they deny coverage, you will not be reimbursed. Ask your insurance company how long the review will take before you decide to pay out of pocket.

Does my insurance cover replacement or repairs if my equipment breaks?

Most plans cover repairs and replacement, but usually only after a certain amount of time has passed — often five years for wheelchairs and three years for smaller items. Check your plan documents or call your insurance company to ask about their replacement policy for the specific item you have.

What if I rent equipment but then do not need it anymore?

Contact the rental company and ask to end the rental. You are usually responsible for returning the equipment in good condition. If your insurance required you to rent before buying and you end the rental early, ask your insurance whether the rental payments still count toward a future purchase — the rules vary by plan.