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Dear Marci,
Dear Marci,
My doctor recommended that I get a manual wheelchair to get around my home. Does Medicare cover wheelchairs? If so, what do I need to do so that they will cover it?
– Gabrielle (Bardstown, KY)
Dear Gabrielle,
Yes, Medicare covers wheelchairs. Wheelchairs, and other items such as walkers and oxygen equipment, are known as durable medical equipment (DME). If you have Original Medicare, DME is covered by Part B (medical insurance). If you have a Medicare Advantage Plan, it covers everything that Original Medicare covers, but may have different costs and rules.
Medicare covers durable medical equipment that is:
- Durable, meaning you can use it again
- Designed to help your medical condition or injury
- Meant for use in your home, although you can use it outside the home
- Likely to last for three years or more
There are a few steps to follow to get Medicare to cover your DME. First, your doctor must prescribe the equipment and certify that you will need to use the equipment in your home.
Next, you should get your DME from an appropriate supplier. For Original Medicare, this depends on where you live. If you live in a region that is part of the competitive bidding demonstration, you will have to get your DME from a supplier that participates in the program. If you live in a region that is not part of the demonstration, you must get your DME through a supplier that has approval from Medicare. You can find a Medicare-approved supplier by visitingwww.medicare.gov/supplier. If you have a Medicare Advantage Plan, you should contact your plan to find a certified supplier.
You will usually rent your equipment from a supplier. For Original Medicare, you pay 20 percent of the cost of the rental fee for 13 months, and then you are usually given ownership. If you are paying a monthly rental fee for your equipment, your supplier must perform all needed repairs and maintenance requiring the work of a professional—without charging you extra. If you own your equipment, Original Medicare will pay 80 percent of the Medicare-approved amount for repairs and maintenance, and you will be responsible for the 20 percent balance. If you have a Medicare Advantage Plan, you may pay a fixed rate or a coinsurance to rent or buy your DME. You can contact your Medicare Advantage Plan to learn about costs and coverage of DME.
Overall, it is important to follow either Original Medicare or your Medicare Advantage Plan’s rules to get your DME covered.
– Marci
Dear Marci,
Dear Marci,
My doctor diagnosed me with obstructive sleep apnea (OSA) and said that I need a continuous positive airway pressure (CPAP) device to help me breathe at night. I have Original Medicare and was wondering whether it will cover the CPAP device.
– Martine (Chesapeake, VA)
Dear Martine,
Original Medicare will cover an initial three-month trial of your CPAP device if you have been diagnosed with obstructive sleep apnea. At the end of the trial, Medicare will continue to pay for the device if your doctor certifies that you have benefited from the device and used it properly.
Before the three-month trial, your physician and supplier must submit paperwork to Medicare to justify your need for a CPAP device. Although it is their job to know these requirements, familiarizing yourself with them can help to avoid errors and navigate any challenges that arise.
To qualify for coverage of a three-month CPAP trial, Original Medicare requires certain steps:
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Your doctor must diagnose you with obstructive sleep apnea based on an examination and subsequent sleep test. This test can be performed in your home or at an approved facility.
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Your doctor must certify that you had a face-to-face exam with him/her or another health professional within the six-month period before the CPAP was ordered.
- You must use a Medicare-approved supplier who provides you and/or your caregiver with instructions about proper use and care for the CPAP device. Many areas including Chesapeake, Virginia are called competitive bidding regions, which means Medicare will usually only pay for most durable medical equipment (DME) from a select group of suppliers, known as contract suppliers.
- Lastly, for continued coverage of your CPAP device following the three-month trial, your provider must re-evaluate you during those initial three months. He or she must certify that the CPAP device is helping you and that you are using it as recommended.
If these conditions are met, Medicare will cover 80 percent of the rental fees for a CPAP device for 13 months, once the Part B deductible is met. After that you will own the device. Note that these 13 months include the three-month trial. Medicare will also pay 80 percent of the cost of CPAP supplies, such as masks and tubing.
On the other hand, if your symptoms did not improve during the initial three-month trial of CPAP therapy, you can re-qualify for Medicare coverage following a new sleep study in a facility, and a re-examination by your physician.
Good luck with this process! Remember, you can always talk with your doctor to stay informed about your health care services.
– Marci
Dear Marci !
Dear Marci,
A few years ago, Original Medicare covered some of the costs of a walker I was prescribed for use in my home. My doctor recently gave me a prescription for oxygen equipment. Is this durable medical equipment like my walker, and will Medicare help pay for it?
– Samir (Dearborn, MI)
Dear Samir,
Yes, oxygen equipment is considered durable medical equipment (DME), and Medicare will help cover its costs.Specifically, Medicare Part B covers DME as long as the equipment is:
- durable, meaning you can use it again
- to help your medical condition
- meant for use in your home, although you are also allowed to use it outside of the home
- likely to last for three years or more
It is important to note that Medicare only pays for DME if you get it from the right kind of supplier. For Original Medicare, this depends on where you live. If you live in a region that is part of the competitive bidding demonstration, you will have to get your DME from a supplier that participates in the program. If you live in a region that is not part of the demonstration, you must get your DME through a supplier that has approval from Medicare. You can find a Medicare-approved supplier by visiting www.medicare.gov/supplier. Note that if you have a Medicare Advantage Plan you should contact your plan to find a certified supplier.
Although supplier restrictions are the same for oxygen equipment as for other types of DME, other coverage rules are different so the process for getting your oxygen equipment will be different from the process you used for getting your walker. Click here if you want to learn more about how Medicare pays for DME.
Unlike other types of DME, oxygen equipment is always rented in a five-year cycle. Medicare will pay the supplier a monthly rental fee for the first 36 months. The fee includes all equipment, oxygen, and supplies. You must pay 20 percent of each month’s rental fee. For the next 24 months, the supplier must allow you to keep the equipment, but Medicare rental payments stop. You pay no more rental fees, although the supplier still owns the equipment. Also, if you use oxygen tanks or cylinders, you must pay a 20 percent coinsurance for liquid or gaseous oxygen each month.
Finally, at the end of five years, you will have the choice to either get new oxygen equipment from your supplier or change to a different supplier.
Throughout this five-year period, the supplier must keep your equipment in good working order. During the first 36 months of the rental period, the supplier must provide you with supplies and maintenance free of charge. During the last 24 months of the rental period, providers are allowed to bill you for in-home maintenance visits every six months.
– Marci
Medicare Reminder
Durable medical equipment (DME) is equipment that helps you complete your daily activities. It includes a variety of items, such as walkers, wheelchairs, and oxygen tanks. Medicare usually covers DME if the equipment is:
- Durable, meaning you can use it again;
- Designed to help a medical condition or injury;
- Suitable to use in the home, although you can also use it outside the home; and
- Likely to last for three years or more.
Medicare will only cover the cost of your DME if your doctor prescribes it and certifies that you need it to get around your home, not just to get around outside of your home.
The cost of your DME and the rules you must follow vary depending on your area and what DME you need. If you have Original Medicare, it will usually cover 80 percent of the cost of your DME and you or your supplemental insurance will be responsible for the remaining 20 percent. This applies to providers who accept assignment, or the Medicare amount as payment in full. If you go to a provider who doesn’t accept assignment, you may have to pay more. Call 800-Medicare or go towww.medicare.gov/supplier to find out your cost and the rules you must follow.
If you have a Medicare Advantage plan, each plan sets its own rates. Contact your plan to find out your cost and the rules you must follow.