Benefit: Durable Medical Equipment

Definition: Durable medical equipment (DME) is equipment that can be used repeatedly, serves a medical purpose, and is appropriate for use in the patient’s home. Medical supplies are medical or surgical items that are consumable, expendable, disposable or non-durable, and are appropriate for use in the patient’s home. Medicaid covers for DME and medical supplies provided by Medicaid participating providers.
DME may be rented or purchased. Examples of reimbursable equipment and supplies include, but are not limited to:

• Ambulatory equipment (canes, crutches, walkers);
• Augmentative and assistive communication devices;
• Blood glucose meters and strips;
• Commodes;
• Diabetic supplies;
• Enteral nutrition (tube feeding) supplements when prior authorized;
• Heparin Lock Flush Syringes;
• Hospital type beds and accessories;
• Insulin syringes;
• Orthotics (foot or lower leg supporting device) and prosthetics (artificial extension of a missing body part);
• Ostomy and urological supplies;
• Oxygen and oxygen-related equipment;
• Peak flow meters;
• Suction pumps;
• Urine Ketone Test Strips; and
• Wheelchairs.

Medical necessity for DME or supplies must be documented by a prescription, a statement of medical necessity, a plan of care, or a hospital discharge plan. The documentation must be signed and dated by the attending physician and include specific information on the item needed, the duration of need, and the recipient’s diagnosis.

Limits:  Limitations to Medicaid reimbursement for DME and medical supplies include:

• Most medical supplies are limited to one per day, per recipient;
• DME and supplies are not covered for recipients in a hospital, nursing facility or intermediate care facility for the developmentally disabled (ICF/DD)
• Some DME services and medical supplies are reimbursable only for recipients 20 years of age or younger; and
• Custom wheelchairs must be prior-authorized.

Exceptions:The following services may be reimbursed for beneficiaries 20 years of age or younger in nursing facilities or ICF/DD:

• Some customized orthotics and prosthetics;
• Customized wheelchairs; and
• Augmentative and assistive communication devices for children 20 years of age or younger.

Co-pays: None

Reform items that can vary: Dollar limits may be imposed; however limits do not apply to orthotics (foot or lower leg supporting device) and prosthetics (artificial extension of a missing body part) over $3,000 and motorized wheelchairs.