Durable medical equipment is basically any piece of healthcare equipment designed for long-term, routine use. As the name suggests, a single piece of durable medical equipment can last for months or even years. The equipment, which may be either rented or purchased, is typically ordered by healthcare providers to help meet a patient’s home care needs.
That could be something as simple as providing increased mobility and sleep quality, or as complex as remotely monitoring the patient’s vitals. In order to qualify for durable medical equipment, you must be able to prove that you need it. This is typically achieved through a document known as a certificate of medical necessity.
That may sound relatively simple on the surface. Unfortunately, it’s anything but. A device classified as durable medical equipment in one scenario might not meet the necessary qualifications in another.
Moreover, in the case of more complex items such as chair lifts, only certain components might meet the classification.
Don’t worry, we’re going to clear the air. We’ll walk you through the basics of durable medical equipment, including the requirements and different classifications. We’ll also give you a crash course in how durable medical equipment is prescribed and regulated—and how your health insurance plays in.
Let’s get started.
What’s Considered Durable Medical Equipment?
Per legal documentation released by the United States Social Security Administration, for an item to be considered durable medical equipment, it must meet the following standards:
- Its primary function must be medical in nature. If a piece of equipment has a non health-related primary use case, it doesn’t matter if it can be used in a medical context. It’s not durable medical equipment.
- It must be intended for everyday use. Durable medical equipment isn’t something one uses only occasionally. It’s meant to be part of a patient’s day-to-day life.
- As the name suggests, it must be reliable and durable. A piece of durable medical equipment should not need regular replacement, but instead should be able to safely achieve its intended purpose for as long as possible—typically three years at the minimum.
- It must be deemed necessary based on the patient’s medical and physical condition. Essentially, this means that durable medical equipment is most commonly prescribed in scenarios where a patient has a disability of some kind.
The wheelchair is among the most common pieces of durable medical equipment, serving a similar purpose to a cane, crutches, or a walker. Believe it or not, prosthetics also fall under the same umbrella, being medical equipment designed to improve mobility and replace motor function. Per the Medicare website, other types of durable medical equipment include:
- Home hospital beds.
- Devices related to Diabetic care, including lancets, lancet devices, and blood sugar monitors
- CPAP machines.
- Internal prosthetic devices such as pacemakers.
- External prosthetic devices such as artificial legs, eyes, or arms.
- Orthotics, including rigid or semi-rigid braces for the arm, neck, and back.
- Oxygen systems and equipment, including tanks, tubing, and machines.
- Certain types of specialized pressure-reducing beds, mattresses, and mattress overlays.
- Nebulizers and their associated medications.
- Home infusion supplies, including pumps, IV poles, catheters, tubing, and certain medications.
- Commode chairs.
- Dialysis machines.
- Chair lifts, though Medicare typically only covers the mechanical components and not the chair itself.
Unfortunately, hearing aids do not fall under the definition of durable medical equipment. Instead, they’re elective medical devices. This means that Medicare has determined they are not medically necessary; one could also make the argument that they lack the necessary durability.
Durable medical equipment and adaptive equipment are frequently conflated with one another, as both are intended to meet the needs of individuals with either short or long-term disabilities. The difference is that adaptive equipment is not primarily medical in nature, nor is it considered medically necessary. Adaptive equipment is also useful to individuals without disabilities or impairments.
Examples of adaptive equipment include:
- Grab bars.
- Leg straps.
- Specialized toilets.
- Specialized utensils and dishware.
- Plate guards.
- Shower chairs.
- Dressing sticks.
- Button hooks.
- Handheld showerheads.
Finally, there are also certain kinds of medical equipment and suppliers that are not defined as durable medical equipment by either Medicare or health insurance providers, including:
- Equipment designed to improve mobility and assist the patient outside their home. This may include motorized scooters along with vehicular attachments such as ramps or lifts.
- Items designed or intended largely for comfort and convenience.
- Certain single-use medical equipment such as surgical facemasks, compression leggings, and catheters. Note that catheters are a special case, as there are certain scenarios in which they do qualify.
- Home renovations such as ramps or widened door frames.
- Medical equipment unsuited or unintended for use within the home and typically only used in hospitals or skilled care facilities.
Does Medicare Cover Durable Medical Equipment?
Durable medical equipment is covered by Medicare Part B, with the caveat that both your doctor and their supplier must both be enrolled in Medicare. This typically requires both parties to meet a number of exacting standards—as such, not all doctors and medical equipment suppliers possess the necessary certifications. It’s imperative that you ask all parties if they are involved in medicare.
At least in part, this is because a supplier that adheres to Medicare can only charge you coinsurance and your part B deductible for any equipment you purchase. A supplier that does not participate in Medicare, however, can charge you whatever they see fit. Additionally, if you attempt to submit a claim to Medicare for equipment purchased from a non-participating supplier, the claim will be rejected.
In addition to the rental or purchase price of durable medical equipment, Medicare also covers any associated medical, technical, and maintenance services associated with that equipment. Note that to qualify for Medicare, you must meet one or more of the following requirements:
- Aged 65 or older.
- A disability that severely impedes motor function, mobility, and/or quality of life.
- End-stage renal disease requiring either dialysis or a kidney transplant.
So what happens if you don’t qualify for Medicare? Or alternatively, what if Medicare refuses, for one reason or another, to cover a piece of equipment you need? What can you do?
That’s the good news. Medicare is far from the only payment option available to you when purchasing durable medical equipment. Many health insurance providers offer some degree of coverage. Typically, this takes one of two forms:
- If you’re lucky, your plan will offer full coverage. Provided you meet the necessary qualifications, you’ll receive your equipment free of charge.
- The equipment might be paid for via coinsurance, meaning you’re responsible for some of the cost but your provider handles the bulk of it.
It’s important to remember that different health insurance providers may have different requirements and restrictions where durable medical equipment is concerned. We strongly recommend contacting your insurance agency and asking them about the coverage offered by your plan.
Medicaid is another option for covering the cost of durable medical equipment. A program provided to low-income Americans, Medicaid follows similar rules and guidelines to Medicare. In order to submit a claim on a piece of durable medical equipment, you’ll need a signed note from your doctor that attests to your needs.
Note as well that Medicaid may cover certain types of equipment and services that Medicare does not,though this depends largely on regulations within your state—your primary care provider should be able to answer any questions you have on the matter.
Finally, if you know you’ll only need your equipment in the short-term, you can save a great deal by renting the equipment instead of purchasing. However, if you’ll need to use durable medical equipment for more than a year or two, you’re probably better off buying it outright. Eventually, rental costs will add up to become considerably higher than the price of buying the equipment outright.
How is Durable Medical Equipment Regulated?
As with most types of medical devices, the Food and Drug Administration regulates the manufacture and sale of durable medical equipment, ensuring it adheres to the necessary safety and quality standards. As part of the review process, medical devices receive a classification from the agency based on their criticality and level of risk to the patient should the device be used or manufactured improperly.
There are three classifications to which a medical device might be assigned:
- Class I devices are low-risk and not critical to the patient’s survival. Examples include hearing aids, non-electric wheelchairs, and bandages.
- Class II devices are slightly more critical, and pose a moderate risk to the patient if they malfunction. Examples include CPAP machines, infusion pumps, and oxygen delivery systems.
- Class III devices are typically crucial to sustaining life, and considered high risk. Examples include pacemakers, high-frequency ventilators, and dialysis machines.
The majority of durable medical equipment is either Class II or Class III. With that said, there are some exceptions such as wheelchairs. Once a piece of durable medical equipment has been approved for sale, The Center for Medicare and Medicaid Services (CMS) shares regulatory responsibility with both state and local governments.
To become a certified durable medical equipment provider, a business must first acquire a National Provider Identifier (NPI) number, which is required by both CMS and commercial health insurance providers. The business must then submit an application to a CMS-approved accreditation company. The company will then assess the applicant based on a set of quality standards which varies by state.
This process typically takes nine months or more, at which point the provider must pay a fee known as a severity bond. Although the bond fee is $50,000, the business only needs to pay between one and five percent. Next, the business must appoint a registered agent to receive legal documentation and notices.
Finally, with all this achieved, the business must register with the licensing authority in its state. Depending on where the organization is located, it may be required to meet a list of additional standards or criteria. This could include registration with the Department of Community Health, a facility inspection report, or approval from the Inspector General.
Suppliers are not the only entity that must be licensed—physicians and care providers must also go through a certification process to become a Medicare Provider. Fortunately, the process is more or less the same for healthcare organizations as it is for retailers. As a certified Medicare Provider, a physician can not only bill Medicare for their services but also order and certify.
Who Can Prescribe Durable Medical Equipment?
Any physician or care provider can feasibly prescribe durable medical equipment to their patients. However, as we’ve already mentioned, if that entity is not properly certified, Medicare will not cover the cost of the equipment. Generally speaking, whether you purchase your durable medical equipment from a supplier yourself or have your healthcare provider do so, you’ll want to ensure you have signed documentation attesting to the need for that equipment.
In the case of Medicare, this takes the form of a Certificate of Medical Necessity, which may include the following information, depending on your state’s requirements:
- The doctor’s official diagnosis.
- The type of product you require, including specifications.
- The quantity of product you require.
- The Initial, revised, and—in the case of equipment such as oxygen tanks—recertification dates.
- Signatures from the beneficiary, supplier, and prescribing physician, along with the dates those signatures were applied.
Where Can I Find Durable Medical Equipment Suppliers?
Broadly speaking, there are three types of durable medical equipment suppliers:
- Durable Medical Equipment Wholesalers work with manufacturers and healthcare organizations. These include hospitals, pharmacies, prescribing physicians, and authorized retailers.
- Durable Medical Equipment Retailers sell to consumers. As with wholesalers, retailers must undergo a state-specific licensing process.
- Medicaid Retailers supply equipment and services directly to Medicaid beneficiaries, and must enroll with their state as a Medicaid provider.