Will Medicare pay for upgrades or special features for my DME?

August 27, 2019


Medicare generally only covers the most basic level of equipment based on your level of medical need. If you want additional features or upgrades, Medicare may be able to cover more—but only if you also agree to pay more. If your supplier thinks that Medicare may not pay for additional features or upgrades, the supplier should have you sign a waiver form called an Advance Beneficiary Notice (ABN) before you get the items. On the ABN, you must check the box stating you want the upgrades and will agree to pay their full cost if Medicare denies coverage for them. Even if Medicare refuses the upgrade, it will still pay the amount it would have paid for the basic model of the equipment.


3How do I replace equipment that is lost, stolen, or worn out?


Replacing equipment means substituting one item for an identical or nearly identical item. For example, Medicare will pay for you to switch from one manual wheelchair to another, but will not pay for you to upgrade to an electric wheelchair or a motorized scooter. Medicare will pay to replace equipment that you rent or own at any time if it is lost, stolen, or damaged beyond repair in an accident or natural disaster, so long as you have proof of the damage or theft. If your equipment is worn out, Medicare will only replace it if you have had the item in your possession for its wholelifetime. An item’s lifetime depends on the type of equipment but, in the context of getting a replacement, is never less than five years from the date that you began using the equipment. Note that this five-year timeframe differs from the three-year minimum lifetime requirement that mostmedical equipment and items must meet in order to fall under Medicare’s definition of DME. The item must also be so worn-down from day-to-day use that it can no longer be fixed.

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