Back to Blog
Medicare

Navigating Medicare Coverage for Durable Medical Equipment (DME)

Navigating Medicare Coverage for Durable Medical Equipment (DME)

Key Takeaways

  • Medicare Part B covers 80% of the cost for medically necessary equipment after you meet your deductible.
  • To qualify, equipment must be needed for use inside your home, not just for outdoor mobility.
  • Always use a Medicare-approved supplier who accepts “assignment” to avoid excess charges.

For many Medicare beneficiaries, staying independent at home relies on having the right tools. Whether it’s a walker to prevent falls, oxygen for COPD, or a hospital bed for better positioning, these items are collectively known as Durable Medical Equipment (DME). While Medicare covers these items, the rules can be confusing and strict. Here is what you need to know to navigate the system effectively.

What Counts as Durable Medical Equipment?

Not every medical device qualifies as DME. To be covered by Medicare Part B, the equipment must meet all of the following criteria:

  1. It must be durable (can withstand repeated use).
  2. It must serve a medical purpose.
  3. It is not usually useful to someone who isn’t sick or injured.
  4. It is appropriate for use in your home.
  5. It is expected to last at least 3 years.

Common examples include: Wheelchairs, walkers, hospital beds, oxygen equipment, patient lifts, and blood sugar monitors.

How Coverage Works: The 80/20 Rule

DME falls under Medicare Part B (Medical Insurance). If your doctor prescribes it and Medicare approves it, you typically pay:

  • 20% of the Medicare-approved amount (coinsurance).
  • The Part B deductible (if you haven’t met it for the year).

Medicare pays the remaining 80%. If you have a Medigap (Medicare Supplement) policy, it will usually cover that 20% coinsurance.

The Tricky “In the Home” Rule

This is the most common reason for denial regarding wheelchairs and scooters. Medicare only covers mobility devices if they are medically necessary for use inside your home.

If you can walk around your house but need a scooter to go to the grocery store or the park, Medicare will likely deny coverage. You must show that without the device, you cannot perform “Activities of Daily Living” (like bathing, dressing, or using the bathroom) within the four walls of your home.

Rent vs. Buy: Who Decides?

You don’t always get to choose whether to rent or buy your equipment. Medicare has different rules for different categories:

  • Capped Rental Items: For items like hospital beds and wheelchairs, Medicare usually rents them for 13 months of continuous use. After that, ownership transfers to you.
  • Oxygen Equipment: Medicare pays a monthly rental fee for the first 36 months, which covers all equipment, oxygen, supplies, and maintenance. The supplier then keeps ownership of the equipment for up to 24 additional months (5 years total), during which you pay no rental fees but may still owe coinsurance for oxygen deliveries and maintenance. At the end of the 5-year period, you can choose to get new equipment from your current supplier or switch to a different one.
  • Inexpensive or Routinely Purchased Items: Basic items like canes, standard walkers, and blood sugar monitors are typically purchased outright. Some more complex walkers (like certain rolling walkers) may follow rental rules instead.

3 Steps to Getting Your Equipment

1. Visit Your Doctor

You need a prescription (called a Standard Written Order). For expensive items like power wheelchairs, you must have a face-to-face exam with your doctor specifically to discuss your need for the device.

2. Find a Medicare-Approved Supplier

This is critical. If you buy from a supplier who isn’t enrolled in Medicare, Medicare won’t pay a dime. Use the tool on Medicare.gov to find approved suppliers in your area.

3. Ask About “Assignment”

Ask the supplier: “Do you accept assignment?” If they say yes, they agree to accept the Medicare-approved amount as full payment. If they say no, they can charge you more, and you might be responsible for the difference.

What to Do If Coverage Is Denied

If a supplier thinks Medicare won’t pay for an item, they must give you an “Advance Beneficiary Notice” (ABN). This form explains why they think Medicare will deny it and how much you will have to pay. You have the right to appeal denials. If you believe the equipment is medically necessary, ensure your doctor’s notes clearly document your specific needs and how the equipment improves your daily function at home.

Getting the Equipment You Need

Medicare’s DME rules are detailed, but the process doesn’t have to be overwhelming. Start with a clear prescription from your doctor, confirm your supplier is Medicare-approved and accepts assignment, and keep records of every conversation and document along the way. If a claim is denied, don’t accept it as the final word—appeals exist for a reason, and many denials are overturned with the right documentation.

If you’re unsure where to begin or running into roadblocks, Amma Advocates can help. From finding the right supplier to making sure your doctor’s notes support your claim, our team knows how to navigate the DME process so you can focus on what matters most—staying safe and independent at home.

Disclaimer: This content is for educational purposes only and does not constitute medical or legal advice. Medicare rules can change; always verify coverage with 1-800-MEDICARE or your State Health Insurance Assistance Program (SHIP).