Many seniors need a little help getting around in their later years. Age-related ailments like arthritis, COPD, and general weakness create mobility problems. Thankfully, Medicare provides good coverage for mobility-related medical equipment under Part B’s Medicare DME benefits. However, you must follow their guidelines.
What is Durable Medical Equipment?
Medicare DME, or Durable Medical Equipment, is equipment that you use in your home based on a medical need. These are devices that you can use repeatedly (durable) and that are usually needed for a long term or permanent basis. Examples are mobility aids like canes, walkers, and wheelchairs; oxygen equipment like concentrators, nebulizers, and CPAPs; and other devices like glucose monitors and hospital beds.
This guide is going to focus on mobility equipment since that is my area of expertise.
How much Does Medicare Pay for DME?
Medicare has an established payment amount for each DME item. When you work with a supplier who is a participating Medicare provider, Medicare will pay 80% of this amount. This leaves you with 20% to pay to the supplier.
There are a few exceptions to this. Some Medicare Advantage or Medicare Supplement plans may cover part or all of this 20% depending on the plan. This site offers a great resource for understanding how those plans work. You can call the number on the back of your insurance policy ID card to verify your particular coverage.
First, there are a few general guidelines you should know about before requesting DME.
You Must Have Part B Coverage
Medical equipment is covered under Medicare’s Part B program, so you must be enrolled in Part B.
Your Doctor Must Accept Medicare
Don’t worry about this requirement too much. Most doctors are participating Medicare providers. They would have told you at your first visit if they don’t accept Medicare. But, you can verify this by using the Medicare Physician Compare tool.
Your DME Supplier Should Be a Participating Provider
This basically means they are also enrolled in Medicare and agree to accept Medicare’s payment for the equipment. This limits the amount you will pay to 20% of the Medicare-approved amount. Non-participating providers may charge you what they wish.
You Cannot Be In a Hospital, Skilled Nursing, or Hospice
Because this equipment is covered under Part B, you cannot be in a medical facility to receive DME. Medicare expects the facility to provide you the equipment you need while you are there under their Part A payment. But, you cannot take this equipment home with you. Usually, the facility will arrange equipment for your home use prior to discharge.
The Equipment Must Be “Reasonable and Necessary”
There are specific requirements for each product, but in general Medicare uses something called MRADL’s to determine your need.
MRADL’s, or Mobility Related Activities of Daily Living, are the things you do at home to take care of yourself. Medicare specifically lists toileting, feeding, dressing, grooming, and bathing as the MRADL’s they will consider. These daily activities are related to mobility because they are performed in certain locations of the home. For example, toileting and bathing are typically done in the bathroom, dressing in the bedroom, etc.
Your mobility status is important for these ADL’s because you need to be able to get yourself to these locations.
So, to qualify for medical equipment, you must have a mobility limitation that interferes with your ability to perform one of the above. This limitation can keep you from doing it at all or within a reasonable time frame. For example, making it to the bathroom on time. Or, the limitation can be that you are at increased risk of falling or injury while attempting the activity.
This is one of the most misunderstood parts of the guidelines.
Think of it this way. If you can safely walk with in your home without any help and take care of your basic needs, you probably don’t qualify. However, if you have a problem getting around your home safely by yourself or you are at risk of falling and it keeps you from taking care of yourself at home, you probably do qualify.
Item Specific Qualifications
Medicare uses a hierarchy when paying for equipment. This means they will only pay for the least expensive item that does the job. So, for mobility equipment, the range is a cane, then a walker, then a manual wheelchair, then a scooter, and finally a power wheelchair.
Canes have the simplest qualifications. First, you have to meet the MRADL requirements I discussed above. Next, you have to be able to safely use the cane and the cane must solve your mobility deficit.
To get your cane, discuss this with your doctor. If your doctor agrees with the need, he or she will give you a prescription for it. Take this prescription to a participating supplier and they will take it over from there. The supplier will send forms for your doctor to sign and then bill Medicare once those forms are received.
The qualifications for a walker are about the same as for a cane. You have to have a mobility limitation that affects your MRADL’s of course. You must be able to safely use a walker and the walker must be the best choice to help you with your mobility deficit.
The paperwork is also the same for a walker. It all starts with a discussion with your doctor.
Rollators, or four wheeled walkers, are considered walkers for Medicare qualification purposes.
Qualifying for a wheelchair gets a little more tricky. Also, because they cost more than other equipment, Medicare scrutinizes these a little more.
Generally, to qualify for a manual wheelchair, you have to meet the criteria discussed above. It also must be documented that you cannot use a cane or a walker, that a wheelchair will fit in the home, and that you are willing to use a wheelchair in the home. “In the home” is critical here. Medicare only considers a wheelchair medically necessary if you need it at home. Outdoor use only will not qualify you. The final criteria is that you have to be able to propel the chair yourself or have a caregiver who is welcome to push it for you.
Some wheelchairs have special guidelines. For example, you can get a lightweight wheelchair if you meet all the general criteria and can propel a lightweight chair but not a standard chair. Or, you can get a hemi-wheelchair (a wheelchair that is closer to the ground) if you are shorter in height or need to move the chair with your feet. And, if you have special sizing needs and need an even lighter wheelchair, you can qualify for that based on your ability to propel it and your measurements. Finally, larger people can qualify for heavy duty wheelchairs based on their weight.
There are other specialty manual wheelchairs too for people with advanced needs due to paralysis, strokes, and other more serious disease.
Your local home medical company can help you and your doctor determine the best type of wheelchair for you.
Power mobility devices are a whole other category entirely. And they have a reputation for being difficult to get to Medicare to approve them. But, this isn’t the truth. If you truly qualify, follow Medicare’s guidelines, and give them the information they ask for, you will get approved. I do it every day!
The actual guidelines for power mobility devices are pages and pages long. Books have been written about them. Rather than go through them one by one, I’d like to give you some good advice on how to get through the process.
- Make sure you meet the base MRADL qualification. If you can use a cane or a walker to get from your couch to your bathroom with minimal difficulty, than Medicare will not pay for a power mobility device for you. They are always going to pay for the least costly piece of equipment that does the job. You will need to show that lower cost devices are not an option.
- Choose a supplier who employs a RESNA-certified Assistive Technology Professional . An ATP is a specialist in wheeled mobility and seating products. They are experts in the products and options that are available. They also understand qualification guidelines and will know what you qualify for and how to get it done. Follow their instructions and do what they say to do.
- Go for a Therapy Evaluation. Do not rely on your doctor alone to gather all the documentation needed. Medicare requires a lot of information and measurements to prove you meet the criteria. This often takes an hour or more for a complete mobility evaluation. Most doctors are not able to take that amount of time for one appointment. Have your doctor refer you to a Physical or Occupational therapist for a thorough mobility evaluation.
If you follow the three tips above and you truly qualify, you will have no problem getting your power device.
Medicare Competitive Bidding
Finally, let’s talk about the Medicare Competitive Bidding process and what that means to you.
Several years ago, Medicare bid out several categories of DME products in high use areas of the country. Only suppliers who won these bids are able to provide those products in those areas. And, there are no exceptions to this rule. To find out if your area is part of the bid with a list of contracted suppliers, search the Medicare Supplier Directory here.
Those of us who work as DME suppliers have some strong opinions about whether or not this program is good for Medicare beneficiaries. We think it limits patient choice which is usually never a good thing. Ok. I’ll get off my soap box now and continue!
However, the Competitive Bid Supplier requirement only applies to original Medicare beneficiaries in certain geographical areas. If you use straight Medicare with your red, white, and blue card, then you probably have to use a contracted supplier.
But, if you have a Medicare replacement plan (Advantage Plan), you are probably exempt from this requirement. You can usually choose any DME supplier who is part of your insurer’s network. If you just have a Medicare supplemental plan (Medigap Plan), you ARE subject to this requirement.
It all depends on what you primary insurance is. You can call Medicare and they will tell you if you are exempt or not.
Medicare does provide a valuable benefit for seniors who need medical equipment. Yet they do have some tight qualification guidelines you must meet. If you meet them, and properly document your need, you won’t have any trouble getting your DME.
Just remember that Medicare will only pay for the least costly piece of equipment that will help you. If you need something more, you will have to prove it to them through medical documentation. All DME requests should start with a face to face visit with your doctor.
I recommend you always use a Participating Supplier to get your equipment at the lowest costs. Consider Medicare Advantage and Supplemental Plans too to help pay co-pays and deductibles. If you need more advanced mobility equipment, only use a supplier who employs an Assistive Technology Professional (ATP).
Follow Medicare’s rules, and you’ll get what you need.
Guest post by Scott Grant, ATP, CRTS® Scott is a dad, grandfather, and custom wheelchair specialist for a local home medical company. When he isn’t working to help seniors live more independent lives, he likes to go for a run, paddle a kayak, or just go outdoors. You can reach him on his Graying With Grace Blog