How coverage for equipment usually works

Why this page has no dollar figures

Coverage amounts, allowables and fee schedules vary by state, by jurisdiction, by plan and by year. A number published on a website is out of date almost immediately, and a stale number is worse than none because people plan around it.

We verify your actual benefit before we supply anything and tell you what we found. That is the only figure worth having.

Medicare Part B

Most durable medical equipment falls under Part B. The general structure: the item must be durable, used for a medical reason, not useful to someone who is not ill or injured, appropriate for use in the home, and expected to last a meaningful period.

Beyond that general definition, individual categories have their own coverage policies with specific clinical criteria. Those policies are published and they are what claims are judged against.

• Some items are purchased, some are rented, and some are ‘capped rental’ where the rental converts after a defined period.
• Some categories require prior authorization before supply.
• You generally pay a share after your annual deductible, and a supplemental plan may cover that share.
• Certain everyday categories — bath safety, most daily living aids, absorbent incontinence products — are generally not covered under Part B at all.

Medicare Advantage

Advantage plans must cover at least what original Medicare covers, but they administer it themselves — their own prior-authorization rules, their own networks, and often their own extra benefits.

Florida Medicaid

Medicaid coverage rules differ from Medicare's, and Florida Medicaid covers some categories Medicare does not — absorbent incontinence products being the notable one. Most Florida Medicaid beneficiaries are in a managed-care plan, which sets its own authorization process.

Commercial plans

Enormously variable. Some mirror Medicare's criteria closely, some are more generous, some exclude whole categories. Deductibles, coinsurance and network rules all apply. There is no useful generalisation beyond: we check yours.

Workers’ compensation and no-fault

A different system again — authorization comes from a carrier against a specific claim and a specific authorized body part. Documentation requirements are heavy because the file may be examined years later.

Related