Insurance & Medicare Guide
Everything you need to know about getting your durable medical equipment covered. Medicare, Medicaid, Medigap, Medicare Advantage — we break it all down.
Medicare Part B & DME
Original Medicare Part B is the primary payer for durable medical equipment in the United States. It covers equipment that is prescribed by a doctor, medically necessary, and intended for use in the home.
Key Coverage Rules
80/20 Cost Share
Medicare pays 80% of the approved amount. You pay 20% after your Part B deductible ($240/year in 2024).
Doctor's Prescription Required
Your treating physician must provide a written order (prescription) stating the equipment is medically necessary.
Enrolled Suppliers Only
The supplier must be enrolled in Medicare and accredited by a CMS-approved organization (ABC, BOC, ACHC, etc.).
Home Use Requirement
Equipment must be appropriate for use in the home. Hospital-grade items generally don't qualify unless adapted.
Rent vs. Purchase
Medicare uses different payment methods depending on the equipment type:
| Method | How It Works | Examples |
|---|---|---|
| Capped Rental | You rent for 13 months, then own the equipment. Medicare pays monthly. | CPAP machines, hospital beds, wheelchairs |
| Purchase | One-time purchase. Medicare pays 80% of the approved amount upfront. | Commode chairs, walkers, canes, crutches |
| Continuous Rental | Rented as long as medically necessary. Supplier maintains the equipment. | Oxygen concentrators, ventilators |
| Supplies | Recurring orders billed monthly or quarterly. | CPAP masks, diabetic testing supplies, CGM sensors |
💡 Assignment Matters: Suppliers who "accept assignment" agree to charge only the Medicare-approved amount. You save money by choosing assigned suppliers — all providers listed on DMEHelper show assignment status.
Medicare Advantage (Part C)
Medicare Advantage plans (Part C) are offered by private insurance companies approved by Medicare. They must cover everything Original Medicare covers — including DME — but the rules often differ.
Key Differences from Original Medicare
Network Restrictions
Most MA plans require you to use in-network DME suppliers. Going out-of-network may mean higher costs or no coverage at all (HMO plans).
Prior Authorization
Many MA plans require prior authorization for DME — especially higher-cost items like power wheelchairs, CPAP machines, and hospital beds. This can add days to the process.
Out-of-Pocket Maximum
Unlike Original Medicare, MA plans cap your annual out-of-pocket spending. Once you hit the max, DME is covered at 100%.
May Include Extra Benefits
Some MA plans offer additional DME benefits not covered by Original Medicare, like over-the-counter health items or extended equipment warranties.
🔍 Check your MA plan's coverage: Use our free benefit checker to look up your specific Medicare Advantage plan. We'll show you copay amounts, prior auth requirements, and in-network suppliers in your area.
Medigap (Medicare Supplement)
Medigap policies are sold by private companies to fill the "gaps" in Original Medicare. They can cover the 20% coinsurance you'd otherwise pay out of pocket for DME.
Medigap Plans That Cover DME Coinsurance
| Plan | Part B Coinsurance | Your DME Cost |
|---|---|---|
| Plan C, D, F, G | 100% covered | $0 after deductible (if applicable) |
| Plan K | 50% covered | You pay 10% (half of the normal 20%) |
| Plan L | 75% covered | You pay 5% |
| Plan M, N | 100% covered | $0 (Plan N may have copays for some services) |
⚠️ Important: Medigap only works with Original Medicare — not Medicare Advantage. If you have a Medicare Advantage plan, you cannot also use a Medigap policy. Plans F and C are not available to people who became eligible for Medicare after January 1, 2020.
Medicaid & Dual-Eligible
If you qualify for both Medicare and Medicaid (a "dual-eligible" beneficiary), you may have little to no out-of-pocket cost for DME.
Full Dual Eligible
Medicaid covers your Medicare premiums, deductibles, and coinsurance — including the 20% DME copay. Your cost: $0 in most states.
Partial Dual (QMB, SLMB)
Some programs cover only the Part B premium. Your DME coinsurance coverage depends on your specific Medicaid category and state rules.
Medicaid DME coverage varies significantly by state. Contact your state Medicaid office or use our benefit checker to understand your specific coverage.
Private / Employer Insurance
If you have private insurance (employer-sponsored, marketplace, or individual), DME coverage varies widely by plan. Here's what to check:
Check Your Summary of Benefits
Look for "Durable Medical Equipment" or "DME" in your plan documents. Most plans cover medically necessary DME but copays and deductibles vary.
In-Network vs. Out-of-Network
Using an in-network supplier typically costs 20-30% less. Ask your insurer for a list of approved DME suppliers in your area.
Prior Authorization
Many private plans require pre-approval for DME over a certain dollar amount. Get this before ordering to avoid surprise bills.
Appeals Process
If your claim is denied, you have the right to appeal. Ask your supplier for medical necessity documentation to support your case.
Insurance Verification Checklist
Before ordering any DME, run through this checklist to avoid surprise bills and coverage denials:
🚀 Shortcut: Skip the phone calls. Use our benefit checker to instantly verify your Medicare or Medicare Advantage coverage online.
Browse Equipment by Category
Find Medicare-approved suppliers for the equipment you need:
Find a Medicare-Approved Supplier
Search by ZIP code or city to find verified DME suppliers near you.