Medicare & DME Glossary

Medicare's guideline that most DME items can only be replaced once every five years (60 months) under normal use. Exceptions apply if equipment is lost, stolen, or irreparably damaged due to accident or a change in medical condition. Your supplier must document the reason for early replacement.

A written notice that a Medicare supplier must give you before providing an item or service that Medicare may not cover. It explains that Medicare might deny payment and estimates your potential cost. If you sign and receive the item, you may be responsible for paying if Medicare denies the claim.

A quality certification required for most DMEPOS suppliers to bill Medicare. Accredited suppliers have been reviewed by an independent organization (such as ACHC or The Joint Commission) and found to meet Medicare's supplier standards. Always verify your supplier is accredited.

A formal process to challenge a Medicare coverage or payment decision. There are five levels of appeal: redetermination, reconsideration, ALJ hearing, Medicare Appeals Council review, and federal court review. You typically have 120 days from the denial notice to file a redetermination.

An agreement where a Medicare-enrolled supplier accepts Medicare's approved amount as full payment for a covered item. Suppliers who accept assignment cannot charge you more than the Medicare coinsurance and deductible. Most DME suppliers must accept assignment to bill Medicare directly.

A person who is enrolled in Medicare and eligible to receive benefits. To be a Medicare beneficiary you must be 65 or older, or under 65 with certain disabilities or End-Stage Renal Disease (ESRD). Your Medicare card shows your beneficiary identification number.

A Medicare measurement of time that begins the day you are admitted for inpatient hospital or skilled nursing facility care and ends when you have been out of the hospital or SNF for 60 consecutive days. There is no limit to the number of benefit periods you can have under Medicare Part A.

A Medicare payment system for certain DME items (like oxygen equipment, hospital beds, and power wheelchairs) where Medicare pays monthly rental fees for a limited period—typically 13 months. After the rental cap, ownership of the equipment transfers to you and Medicare stops paying.

A form completed and signed by your doctor that certifies you need specific DME for a medical condition. Medicare requires a CMN for many items including oxygen, CPAP machines, and power wheelchairs. Without a valid CMN, Medicare will deny the claim.

The federal agency within the U.S. Department of Health and Human Services that administers Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). CMS sets coverage policies, payment rates, and quality standards for all Medicare services including DME.

Your share of the cost for a covered health care service, calculated as a percentage of the allowed amount. For most Medicare Part B DME, coinsurance is 20% after you meet your deductible. For example, if Medicare approves $100 for an item, you owe $20 and Medicare pays $80.

A Medicare program that uses a bidding process to set payment amounts for certain DME in specific geographic areas. Suppliers compete for contracts by submitting bids, which lowers Medicare costs. If you live in a competitive bidding area, you must use contract suppliers to have Medicare pay for certain items.

The process used when you have more than one health insurance plan to determine which plan pays first (primary) and which pays second (secondary). Medicare may be primary or secondary depending on your other coverage, such as employer group health insurance or Medicaid.

A fixed amount you pay for a covered health care service or item, as opposed to a percentage (coinsurance). Medicare Advantage plans commonly use copayments for DME instead of the 20% coinsurance used in Original Medicare. Your plan's Evidence of Coverage document lists specific copay amounts.

A therapy device that delivers a constant stream of pressurized air to keep your airway open during sleep, used to treat obstructive sleep apnea. Medicare covers CPAP equipment as a capped rental for 13 months when you have a qualifying sleep study diagnosis and meet clinical criteria.

A Medicare claim that is automatically forwarded to a secondary insurer (such as Medicaid or a Medigap plan) after Medicare processes it. Crossover claims save you time because you don't have to file a separate claim with your secondary insurer. Most Medicare claims cross over electronically.

The amount you must pay for covered health care services before Medicare begins to pay. In 2026, the Medicare Part B deductible is $288 per year. You must meet this deductible before Medicare pays its share for DME, outpatient services, and other Part B items.

Equipment that is primarily and customarily used to serve a medical purpose, can withstand repeated use, is not useful to a person in the absence of illness or injury, and is appropriate for home use. Examples include wheelchairs, walkers, CPAP machines, hospital beds, and oxygen equipment.

A private company that contracts with CMS to process Medicare DME claims in a specific jurisdiction. There are four DME MACs covering different regions of the United States. They determine coverage, process payments, and handle redetermination appeals for DME claims.

The broader category of Medicare-covered items beyond just durable medical equipment, including prosthetics (artificial limbs), orthotics (braces and supports), and medical supplies (like catheters and diabetic testing strips). Medicare Part B covers most DMEPOS items when medically necessary.

A person who qualifies for both Medicare and Medicaid. Dual eligible beneficiaries often pay little or nothing for covered health care services because Medicaid may cover Medicare's cost-sharing (deductibles, coinsurance, copayments). Special programs exist to coordinate their care and benefits.

The electronic transmission of a prescription or medication order from a prescriber to a pharmacy or DME supplier. For DME, e-prescribing allows doctors to send orders directly to suppliers, reducing paperwork errors and speeding up the equipment delivery process.

A required in-person or telehealth visit between a patient and their treating physician that must occur within a specific time period before certain DME orders are valid. Medicare requires face-to-face encounters for items like power mobility devices and home health services to confirm medical necessity.

A list of Medicare's approved payment amounts for specific DME items and services. The DMEPOS fee schedule is published annually and varies by geographic location. Suppliers who accept assignment cannot charge more than the fee schedule amount plus your deductible and coinsurance.

A standardized system of codes used to describe medical items and services for billing purposes. DME suppliers use HCPCS Level II codes (alphanumeric codes starting with letters A-V) to identify specific equipment on Medicare claims. For example, E0601 is the code for a CPAP device.

Alphanumeric codes used to identify products, supplies, and services not included in CPT codes, including most DME items. Level II codes begin with letters A through V. Suppliers must use the correct HCPCS code on Medicare claims to receive payment for a specific item.

A Medicare-certified organization that provides skilled nursing care, therapy, and other health services in your home. Home health agencies are separate from DME suppliers but often coordinate equipment orders for patients receiving home health care. You must be homebound and need skilled care to qualify.

A Medicare benefit for people with a terminal illness who choose comfort care over curative treatment. Under hospice, Medicare covers DME related to your terminal diagnosis—including hospital beds, wheelchairs, and medical supplies—at no cost to you. Hospice is covered under Medicare Part A.

A 7-month window around your 65th birthday during which you can first enroll in Medicare Part A and Part B. The period begins 3 months before your birthday month and ends 3 months after. Enrolling late can result in a permanent late-enrollment penalty added to your monthly premium.

A DME supplier that has a contract with your Medicare Advantage or supplemental insurance plan to provide services at negotiated rates. Using an in-network supplier typically results in lower out-of-pocket costs. If you use an out-of-network supplier, you may pay significantly more.

A decision by a DME MAC that defines when and under what clinical circumstances a specific item or service is considered medically necessary and covered by Medicare in that contractor's jurisdiction. LCDs list covered diagnoses, documentation requirements, and coding guidance for DME suppliers.

A legal agreement you sign with a Medicare supplier stating that the supplier will always accept assignment (Medicare's approved amount) for items they supply to you. This protects you from ever being balance-billed more than the Medicare cost-sharing amounts.

A joint federal and state program that helps with medical costs for people with limited income and resources. Medicaid can cover DME and services that Medicare doesn't cover or pay the cost-sharing amounts Medicare leaves. Eligibility rules and benefits vary by state.

A Medicare requirement that a service or item must be reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body part. Without documented medical necessity, Medicare will deny payment for DME even if your doctor ordered it.

Also called Medicare Part C, this is an alternative to Original Medicare offered by private insurance companies approved by Medicare. Medicare Advantage plans must cover everything Original Medicare covers but may charge different cost-sharing for DME and require you to use in-network suppliers.

The part of Medicare that covers inpatient hospital stays, skilled nursing facility care, hospice care, and limited home health services. Part A covers DME only in very limited circumstances (hospice, SNF stays). Most DME is covered under Part B.

The part of Medicare that covers outpatient services, including most durable medical equipment, doctor visits, preventive services, and laboratory tests. Part B pays 80% of approved DME costs after you meet your annual deductible; you are responsible for the remaining 20% coinsurance.

The voluntary prescription drug coverage program added to Medicare in 2006. Part D is offered by private insurers and covers prescription medications. It does not cover DME but some Part D plans may cover diabetic testing supplies and insulin when dispensed by a pharmacy.

Private health insurance sold to Medicare beneficiaries to help cover gaps in Original Medicare coverage, such as coinsurance, copayments, and deductibles. A Medigap plan may pay the 20% DME coinsurance that Original Medicare leaves, reducing your out-of-pocket costs to near zero.

A set of federal laws that determine when Medicare pays primary or secondary to another insurance. If you have employer group health coverage, workers' compensation, or liability insurance, Medicare may be secondary—meaning your other insurer pays first. MSP rules prevent Medicare from paying unnecessarily.

A nationwide decision by CMS about whether Medicare will cover a specific item or service. NCDs apply uniformly in all states and take precedence over local coverage determinations. For example, NCDs exist for power mobility devices, continuous positive airway pressure (CPAP), and infusion pumps.

A unique 10-digit identification number issued to health care providers and suppliers by CMS through the NPPES system. All Medicare-enrolled DME suppliers must have an NPI. You can verify a supplier's NPI to confirm they are legitimate and enrolled in Medicare.

The database maintained by CMS that assigns National Provider Identifiers (NPIs) and stores information about health care providers and health plans. You can use the NPPES registry to verify a DME supplier's NPI and confirm their enrollment status.

External devices such as braces, splints, and supports that are used to align, support, prevent, or correct deformities or improve the function of movable body parts. Medicare Part B covers medically necessary orthotics when ordered by a physician for a documented diagnosis.

Medically prescribed equipment that delivers supplemental oxygen to patients with conditions like COPD or heart failure. Medicare covers oxygen equipment as a capped rental for 36 months; after that the supplier must continue providing the equipment and servicing for the next 24 months.

Medically necessary nutrition therapy delivered either intravenously (parenteral) or through a feeding tube (enteral) when a patient cannot eat by mouth. Medicare Part B covers this under the DMEPOS benefit for patients with a permanent impairment of the digestive tract.

Motorized wheelchairs and scooters covered by Medicare Part B when you have a mobility limitation that significantly impairs your ability to participate in activities of daily living in the home. A face-to-face exam and specific CMN from your doctor are required.

Advance approval from Medicare or a Medicare Advantage plan that is required before you receive certain high-cost DME items. Without prior authorization, Medicare may deny the claim. Required items currently include power mobility devices, lower limb prostheses, and certain orthotics.

Artificial limbs and other devices that replace all or part of a missing body part. Medicare Part B covers medically necessary prosthetics when ordered by a physician after an amputation or due to a congenital absence of a limb. Fitting by a certified prosthetist is required.

The process by which a DME supplier applies to and is approved by Medicare to bill for services. Suppliers must meet strict enrollment requirements including accreditation, surety bonds, and site inspections. Only enrolled suppliers can submit claims to Medicare.

The specific medical condition or ICD-10 diagnosis code that makes a patient eligible for Medicare coverage of a particular DME item. LCDs and NCDs list qualifying diagnoses for each item. If your diagnosis is not on the covered list, Medicare will deny the claim.

The duration for which Medicare pays monthly rental fees for certain DME items before ownership transfers to you. For most capped rental items, the rental period is 13 months of continuous use. Medicare pays 80% of the monthly rental amount while you pay the remaining 20% coinsurance.

Medicare's guidelines for how often specific DME items and supplies can be replaced. Most equipment is subject to a 5-year replacement rule, while supplies like CPAP masks, tubing, and diabetic test strips have shorter replacement schedules. Always check with your supplier for your item's specific schedule.

A facility that provides short-term skilled nursing care and rehabilitation services after a qualifying hospital stay. Medicare Part A covers SNF care up to 100 days per benefit period. DME needs during an SNF stay are covered by the SNF's per diem rate, not separately under Part B.

A Medicare-certified facility that provides short-term skilled nursing and rehabilitation care. Medicare covers SNF stays for up to 100 days per benefit period following a qualifying 3-day inpatient hospital stay. Days 21–100 require a daily copayment from the beneficiary.

CMS requires that all DMEPOS suppliers be accredited by a CMS-approved accreditation organization before enrolling in Medicare. The accreditation verifies that a supplier meets quality standards. Common accreditation organizations include ACHC, The Joint Commission, and HQAA.

The 30 conditions that a DMEPOS supplier must meet to enroll in and maintain their Medicare billing privileges. Standards cover business operations, product quality, patient service, and documentation requirements. Suppliers who do not meet these standards can be revoked from Medicare.

Health care services provided via video or phone instead of in-person. Medicare expanded telehealth coverage significantly during and after the COVID-19 pandemic. For DME, a telehealth visit can satisfy the face-to-face requirement for some equipment categories, making it easier to get your order processed.

A process used by Medicare and insurance plans to evaluate whether health care services, including DME, are appropriate, medically necessary, and cost-effective. Utilization review may occur before, during, or after services are provided and can result in coverage denials or approvals.

A Medicare requirement that a supplier must have a written or electronic order from the treating physician before delivering certain DME items to a patient. The order must be signed and dated before the item is dispensed. Delivering without a WOPD can result in claim denial.