The answer to this question is: "It depends." Medicare, federal insurance available to individuals 65 and over, disabled individuals, or persons with permanent kidney failure, has two types of insurance, Medicare Part A and Medicare Part B. Durable medical equipment is only partially covered under Part A if the insurance beneficiary (the patient) qualifies for the Home Health Benefit. This means that the patient must be incapable of leaving his/her residence, requires skilled nursing care and does not require only custodial care (bathing, toileting, etc.). If the patient does qualify for such benefits, then Medicare will cover 80 percent of the allowable amount for medically necessary durable medical equipment. Each state sets its own allowable amount for each item. For example, if a patient requires a specialized walker that costs $200 (assuming that all parties deem it medically necessary), and the allowable amount for walkers in that particular state is $100, then the patient would be required to pay $120 for the walker (80 percent of the allowable amount plus the difference between the allowable amount and the cost).
Under Medicare's Part B, the co-pay is the same - 20 percent of the allowable amount and any additional expense after that. However, the patient does not have to qualify for the Home Health Benefit. If the physician or the physical or occupational therapist considers it medically necessary, then the patient can acquire partial reimbursement for the walker.
Medicare, however, does not cover all types of durable medical equipment. Hearing aids are not covered, and usually home adaptation items, such as lifts, grab bars for bathroom safety and ramps are not covered either. However, this can vary by state.
Medicare does not generally cover disposable medical supplies, although there are some exceptions for patients with diabetes, ostomy patients and patients with feeding tubes. What Medicare does cover, however, is severely limited. Ostomy supplies, for example, are limited (depending on which product) to a certain number per month. A patient can appeal this limitation to receive additional items, but is only through an involved process including re-approval by a doctor and Medicare.
Medicaid, a federal-state program that insures populations with extremely low incomes, also varies state by state, but usually covers a wider selection of equipment and supplies and a larger portion of the expense (if not all of it) than Medicare. Medicaid, for example, covers the costs of hearing aids, as long as the patient fulfills certain criteria (i.e., has a severe hearing loss, is visually impaired or is cognitively impaired). Medicaid does not have the same strict limitations on duration of use and the number of supplies as does Medicare.
Another government program that is particularly helpful in providing durable medical equipment is the Veterans Administration (VA). The VA has extensive experience in this field and is a major resource for eligible persons.
As a general rule, private insurance companies do not pay for disposable supplies for home use. However, it does not hurt to ask. You may get some partial reimbursement, but most often the answer will be that these costs are the patient's responsibility. This is not a trivial cost: incontinence supplies alone may run up to $200 or $300 a month.
Many of these disposable items are available through mail order catalogs and on the Internet. They are also more or less readily available in your local community. Adult incontinence products, for example, are available at wholesale store chains, which generally have more competitive prices than medical supply companies. However, these stores may not carry as wide a variety of products as are available through catalogs or medical supply stores. If you need a special size or type of product, you may not be able to buy it off the shelf.
Disease-specific or medically necessary supplies, such as ostomy bags and parenteral and enteral nutrition, are at least partially covered by some private insurers. Careful research by the consumer is necessary in these situations because, although having the insurer pay for some of the cost may seem like the best deal, it may not be. A consumer may find that purchasing the item at a non-contracted or "out of network" vendor whose price is lower ends up costing less in the end. It is also possible that the convenience of using an out-of-network vendor might provide a better value, despite any extra cost. That vendor may be willing to deliver, keep track of your order, call with reminders about reordering or send regular shipments and otherwise provide the kind of service that counts for a lot. It is important, to say the least, not to run out of essential supplies. Delivery of bulky items can also be a great help, especially if transportation is a problem.
Even with the most generous insurance coverage, it is unlikely that the entire cost of durable medical equipment will be covered. Even if a private insurance policy covers durable medical equipment, the company will generally approve only the lowest level of equipment or provide a modest payment toward the cost of a more costly item. These decisions can be appealed if there is extensive medical justification, but the outcome is far from certain.
When third-party payers are involved in the purchase or rental of major durable medical equipment, a doctor's order for the item or for an evaluation by a trained therapist is necessary. The evaluator should be someone who has expertise in that specific piece of equipment, preferably a certified physical therapist or occupational therapist. Generally the therapist and the vendor work together with the patient and caregiver to determine the patient's needs and the available options. The third-party payer may determine the choice of therapist and vendor. All third-party payers now contract with one or more vendors who supply particular types of equipment. Of course you may choose another vendor, but there is no guarantee that the insurer will pay the full amount or any amount in that case. You should ask for a list of approved vendors, but recognize that you might have difficulty obtaining it.
Supply companies may also be regionally specific. If you live in Florida, you may only be able to order supplies from a company based in Florida, whether or not they supply what you need or have the best prices.
The choice of whether to rent or buy durable medical equipment is often made by the insurance company. If they decide on rental, then the equipment must be returned to the company that provided it after it is no longer needed. Customers who will be paying for expensive items must decide for themselves whether it is better to rent or buy. For very short-term use rental is clearly the better choice, although many vendors have minimum rental periods of a month. When the item must be customized, such as a wheelchair for a severely disabled person, purchase is probably the only option. There is a private market in resale of some used or previously owned wheelchairs, scooters, and especially outfitted handicap vans. Usually these are advertised in disability newspapers or on the Internet.
Small items such as special can openers, TV remote control devices and aids for dressing are available from medical supply or self-care catalogs or on the Internet through home care product Web sites. Payment for these items is always the patient's responsibility.
What to remember when purchasing medical supplies and equipment
Medical supplies and durable medical equipment that a patient may have used in various facilities may not always be the proper, most effective or best product for the patient. Incontinence products used in a rehabilitation facility may have been given to the patient simply because they were cost effective or readily available. These products are generally not tailored to the specific needs, body size and preferences of each patient. Therefore, the brand with which you are familiar may not always be the best product for the patient. Learning about the range of products and their differences becomes increasingly important when deciding which item to purchase. Although a tiresome method, trial and error may be the best way to find the right product for the patient.
Although a hospital bed or a standard wheelchair can be delivered in a day, situations arise in which the delivery of customized durable medical equipment might be delayed for months. It is not uncommon for the insurance company's period of authorization to run out before the equipment arrives, requiring the whole process to be started again. Delays also might occur when there are complex product specifications, miscommunication between vendor and payer or insurance problems. Any or all of these problems can make the process painstakingly slow. Despite all best efforts, the wrong product still may be delivered. Again, careful and frequent inquiries and documenting all phone, in-person and written communications are advisable in order to avoid misunderstandings and to keep the process progressing smoothly.
Maintenance of equipment and observing the efficacy of medical supplies
Post-delivery evaluation, maintenance and modifications are also extremely important. Even if the correct product is delivered, it may prove inadequate for the patient, due to miscalculation of need in the original assessment and may cause discomfort or increased disability. Observe how the product works for both the patient and the caregiver. Is it uncomfortable? Is it working? Does it cause unnecessary pain? If so, perhaps trying another type of product might remedy the situation. As the caregiver, it is important not to underestimate your own perspective of the patient's needs and condition.
Correct and adequate maintenance of durable medical equipment also is imperative. Oxygen for respiratory therapy and nebulizers are particularly complex. Safety and sterilization are two extremely crucial issues for these types of durable medical equipment because the health and well being of the patient and the entire family are at stake. All forms of home oxygen therapies need to be kept away from heat or flames, as oxygen is extremely flammable. Nebulizers need to be cleaned after each use and sterilized often; otherwise the health of the patient is seriously compromised.