How Do I Get Durable Medical Devices?

Understanding What DMEs Are

Durable Medical Equipment (DME) refers to devices that assist individuals in performing daily activities and managing health conditions within the home. These items are designed for long-term use and are considered critical to the health and well-being of patients who require medical support outside of traditional healthcare settings. This article provides comprehensive guidance on obtaining such equipment, particularly through Medicare and Medicaid programs.

Eligibility and Documentation Requirements for DME

What are the eligibility requirements and necessary documentation for acquiring DME?

To acquire Durable Medical Equipment (DME) through Medicare, several eligibility criteria must be met. Primarily, a written prescription from a Medicare-enrolled healthcare provider is necessary. This prescription should state that the equipment is medically necessary and intended for home use due to a medical condition.

Patients must also schedule an in-person visit with their doctor. This face-to-face encounter is crucial as it is part of the documentation process. The doctor will review the need for DME and provide an order if deemed necessary. This encounter must be documented in the patient's medical record.

For items requiring replacement, a new prescription must be submitted each year, reinforcing the ongoing medical necessity. If purchasing DME costs over $100 or rental exceeds $50 in a calendar month, prior authorization must be obtained from Medicare.

In addition to the doctor’s prescription, specific documentation relating to the medical condition should be included to justify the request. Using the correct claims modifiers is essential in the submission process, ensuring proper reimbursement and compliance with Medicare regulations.

Medicare Coverage for Durable Medical Equipment

How can I obtain durable medical equipment through Medicare and Medicaid?

To obtain durable medical equipment (DME) through Medicare and Medicaid, you must first secure a prescription from a Medicare-enrolled healthcare provider indicating that the equipment is medically necessary and intended for home use. Medicare Part B typically covers 80% of the equipment costs after reaching the deductible. It's crucial to acquire the DME from an approved supplier, especially if residing in a competitive bidding area. Common DME items include wheelchairs, hospital beds, and oxygen equipment. If you're also eligible for Medicaid, it might help cover some costs that Medicare does not. Always confirm eligibility since certain items, especially disposable or non-medically necessary modifications, may not be covered.

What types of durable medical equipment are covered by Medicare?

Medicare covers various types of durable medical equipment (DME) that meet the criteria of medical necessity. Some examples include:

• Blood Sugar Meters
• Wheelchairs and Hospital Beds
• Oxygen Equipment
• CPAP Machines
• Canes and Crutches
  Most DME must be rented, although some options allow for purchase, with ownership transferring after a designated rental period. After you meet the Part B deductible, beneficiaries usually pay 20% of the approved amount for DME from a supplier who accepts assignment. Note that items used for convenience, home modifications like ramps, and most disposable items are generally not covered under Medicare.

Costs associated with DME

When utilizing Medicare for DME, after reaching your Part B deductible, you are responsible for 20% of the Medicare-approved costs. It's advisable to ensure your supplier participates in Medicare to minimize out-of-pocket expenses. The specifics of costs can vary based on the item's nature and the area's competitive bidding implications. Additionally, if you qualify for Medicaid, some cost-sharing amounts may be covered under those plans.

Requesting DME Through Approved Suppliers

How do I request durable medical equipment through approved suppliers?

To successfully request durable medical equipment (DME) through approved suppliers, you must first ensure that the supplier holds DMEPOS accreditation issued by a CMS-approved organization and is enrolled in the Medicare program. Start by obtaining a National Provider Identifier (NPI) for each practice location and completing the Medicare enrollment application in the PECOS system.

What is the role of suppliers in providing DME?

Suppliers play a crucial role in providing DME. They are responsible for ensuring that all equipment meets the necessary medical standards and is suitable for home use. After accreditation, suppliers can submit a Prior Authorization Request (PAR) to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) to confirm coverage before delivering the equipment.

Why is the accreditation of suppliers important?

Accreditation is vital for suppliers as it ensures compliance with Medicare standards, ultimately leading to better care for patients. Accredited suppliers must also post a surety bond and pay the Medicare application fee (which is $688 for 2023). This process reinforces the quality and reliability of DME services, protecting patients while facilitating efficient access to medically necessary equipment.

Stage	Details	Importance
Supplier Accreditation	DMEPOS accreditation from a CMS-approved organization	Ensures compliance with Medicare standards
NPI Registration	Obtaining a National Provider Identifier for practice locations	Required for Medicare enrollment process
Prior Authorization	Submitting a PAR to DME MACs for coverage confirmation	Confirms medical necessity before equipment provision
Surety Bond & Fees	Posting a surety bond and paying the Medicare application fee	Ensures financial responsibility and credentials

Medicare’s Competitive Bidding Program

What is Medicare's Competitive Bidding Program and how does it impact DME access?

Medicare's Competitive Bidding Program (CBP) was implemented in 2011 to help lower the costs of durable medical equipment (DME). The program sets payment amounts based on the bids submitted by suppliers, promoting competition among them. This has resulted in substantial savings, with reports indicating a 41.8% reduction in spending on twelve key DME items. For instance, CPAP devices saw a notable decrease of 47.2% in costs.

However, while the program effectively reduces prices, there are implications for access to DME. Statistics show that after the CBP was initiated, there was a 4.3% decline in utilization of DME. This change may hinder access for some beneficiaries, particularly those who require multiple items or do not have specific medical diagnoses. Critics highlight concerns that the cost-saving focus of the contract supplier model could limit competition and availability of certain items, potentially leaving patients in need of specialized equipment underserved.

What are competitive bidding areas and supplier requirements?

In regions known as competitive bidding areas, obtaining DME requires using suppliers who have won contracts through this bidding process. To qualify, suppliers must be Medicare-approved and agree to Medicare's payment amounts, covering goods like wheelchairs, oxygen equipment, and walkers. If a beneficiary needs DME in these areas, they must select from these designated suppliers to ensure coverage through Medicare.

The careful balancing of cost and access under the CBP is critical, as Medicare beneficiaries navigate their medical needs while adhering to these new supplier mandates.

Resources and Contacts for Accessing DME

What resources, contacts, and programs are available for acquiring DME?

To acquire Durable Medical Equipment (DME), several resources and programs are readily accessible. One primary source is the UMWA Funds, which cover most DME items upon receiving a doctor’s order. This equipment must be obtained from designated DME Program Vendors, including well-known suppliers like American Home Patient and Community Home Care Services.

In addition to these common suppliers, patients may find specialty vendors such as Binson’s Hospital Supplies and Liberator Medical Supplies, which cater to specific medical needs. This creates a streamlined way to access equipment suited to various health conditions.

Members under Coordinated Care programs can also directly order DME through specialized channels provided they have a valid prescription. For more options, patients can refer to the preferred vendors listed on associated health plan websites.

Support Resources and Important Contacts

For individuals seeking financial assistance beyond their primary plan, Medicare and Supplemental Security Income (SSI) may offer additional funding for necessary DME. To navigate these options effectively, it is advisable for users to reach out to resources such as:

• Medicare.gov for information on contract suppliers
• 1-800-MEDICARE (1-800-633-4227) for inquiries about coverage eligibility and supplier services

Utilizing these resources ensures individuals can acquire needed DME efficiently, maximizing their healthcare support.

Key Takeaways on DME Acquisition

Obtaining durable medical equipment involves understanding specific eligibility requirements, navigating the complexities of Medicare and Medicaid coverage, and utilizing resources that assist in the acquisition process. Patients must actively engage with approved suppliers and stay informed about programs like the Competitive Bidding Program to make the most cost-effective and beneficial choices. As regulations can change, it's crucial to consult with healthcare providers and keep abreast of the latest information to ensure that necessary medical equipment is accessible and affordable.

References

• Durable medical equipment (DME) coverage - Medicare
• [PDF] Your Guide to Medicare's Durable Medical Equipment ... - CMS
• Medicare coverage for durable medical equipment - Humana
• Durable medical equipment Medicare covers for home use
• Maryland Durable Medical Equipment Re-Use
• Durable Medical Equipment: What Does Medicare Cover? - Healthline
• Durable Medical Equipment (DME) Requirements–Information for ...
• Durable medical equipment licensing requirements - Wolters Kluwer
• Durable Medical Equipment (DME) | Washington State Health Care ...
• What Is Durable Medical Equipment? | Liberty Home Care and ...