If you’ve ever needed to order durable medical equipment (DME) to use at home, you know how frustrating it can be trying to figure out what you insurance company covers vs. what they don’t cover. Or maybe you’ve wondered why it takes so long for a new wheelchair to be delivered. There is a lot to know about ordering DME so we’ve compiled a list of tips in order to help you be a good DME consumer.
What Is vs. What Is Not Covered
- In general, shower chairs are never covered by insurance companies. This includes roll-in shower chairs.
- Wheelchair ramps and stairglides for the home are also not covered by insurance companies.
- Insurance companies will typically cover only one mobility aid at a time, meaning if you need a manual wheelchair, they won’t pay for your rolling walker. Or if you need a prosthetic leg, they won’t pay for your wheelchair. It’s important you request your insurance company pay for the most expensive mobility aid so as to avoid having to shell out more money for any additional aids.
- Insurance companies will usually pay for new DME every five years, unless there is a significant change in functional status or weight. This is not a guarantee though for items like wheelchairs, if appropriate modifications can be made to the wheelchair without having to order an entirely new one.
Differences in Purchasing and Renting
- Bathroom DME like commodes and shower chairs are always purchased, not rented. My guess is not many people want to rent a used commode…
- Hospital beds and some manual wheelchairs can be rented for a period of up to 13 months. If you end up keeping them for 13 months or more, you own them. By that point, the insurance company has paid enough in rental fees to purchase the item from the vendor.
- Rental hospital beds are semi-electric, meaning the head of the bed is electric but the height of the bed is changed by using a manual crank. They also do not come with sheets. Lastly, the hospital beds insurance companies will cover are unfortunately not as nice as the ones we have for our patients at Magee. I try to share this with my patients before going home so it’s not such a shock to them when theirs doesn’t look like ours.
- Insurance companies will only cover a pressure reducing mattress (also known as a group 2 mattress) if a patient has a wound present at the time of discharge from the hospital.
- When a new permanent wheelchair is being ordered it typically takes 2-4 months (can be longer though) before the permanent wheelchair is delivered. It usually takes that long for your insurance company to authorize the wheelchair and for the manufacturer to build a customized chair. The good thing to know is that you will go home with a loaner wheelchair in the meantime.
- When ordering a power wheelchair (PWC), you typically go home with a manual wheelchair until your permanent PWC is finished being built. This is because vendors generally do not have PWCs available to loan to the pt.
- Some insurance companies require a home assessment or drive-by of the patient’s home to be completed by the vendor to ensure the entry way is accessible before they will authorize the purchase of a new PWC.
Paying for DME
- Always be sure to ask your case manager or DME vendor about any insurance co-pays before your DME is delivered so you don’t get sticker shock.
- Keep an eye out for organizations that loan out DME for free to patients with specific diagnoses. The ALS Association and Muscular Dystrophy Association of the Philadelphia area are two such organizations.
- Help Hope Live, Indegogo, and Go Fund Me are good options to help you raise money to fund DME not covered by insurance. Just know that putting money from a fundraiser in your own bank account can impact your Medicaid eligibility, if applicable. Help Hope Live is a non-profit that manages the money for you; therefore, your Medicaid eligibility will not be impacted.
- For the items that aren’t covered like showers chairs, Amazon.com and Walmart are great places to buy them at a seriously reduced cost.
This blog post topic was suggested by Magee’s Patient Advisory Council. If you are interested in joining the PAC or would like to learn more, please contact Marci Ruediger, Director of Performance Excellence at 215-587-3454 or firstname.lastname@example.org.