What’s Happening to Durable Medical Equipment Coverage?

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By Kim Cantrell, CFILC’s Director of Programs

Over the past several years private health insurance companies have slowly and steadily reduced durable medical equipment (DME) coverage. If you belong to a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO) and are not enrolled in Medi-Cal or Medicare, then your DME coverage limits may have taken a nosedive in recent years.

If you don’t need DME, then chances are you haven’t noticed the reduction or realized its consequence. For people who rely on DME, you are probably very aware of the coverage changes because it means that out-of-pocket costs have skyrocketed.

Years ago if you had private health insurance and needed a wheelchair, your health insurance company would cover a percentage of the cost of a new chair, usually between 70-90%. If you needed to purchase a $10k wheelchair, you would pay between $1-3k and the insurance company would cover the rest. The out-of-pocket amounts were still large, and it created a real burden on many families.

Within the last ten years DME coverage has become even more restrictive. Many companies are covering 50-80% of DME cost, but only up to an annual maximum amount, typically $2,000. This means that your out-of-pocket expense for that same $10k wheelchair would be over $8k, which is a lot more than $3k.

These coverage changes affect how often people can afford to purchase DME. People are still purchasing shower chairs, bedside commodes, and other low-cost items that fall within coverage limits, but the high-cost items are frequently out of reach. People are going without manual and power wheelchairs and other high-cost DME items. And when they do, they lose the independence their DME would have given them.

The AT Network receives many calls from people who have private health insurance and still cannot afford to buy DME. They simply cannot afford the expense. Even though they have health insurance, it is not enough to cover what they need, and they call us looking for low-cost alternatives.

We live in a world of rising health care costs. Advancements in medical technology are expensive. I understand that health insurance companies are trying to control costs where they can, especially in places where many people will not notice. However, reducing DME coverage by imposing annual caps hurts people who already bear a large financial burden for their health care.

If you have private health insurance, do you have an annual cap on DME coverage? What kind of out-of-pocket costs are you paying?

4 thoughts on “What’s Happening to Durable Medical Equipment Coverage?

  1. I have Aetna health coverage… kinda…
    what I mean is, I have had Aetna for the past 12 years. Rarely do I go to the doctor, (I’m a former Army Ranger, we just don’t go to doctors unless we are missing a limb). So, one day my wife tells me she is really worried… say’s I stop breathing when I’m sleeping, then I gasp for air. Ok fine, I goto the doctor… long story short… I have sleep apnea… I’m told I stop breathing about 20 times an hour and so are as long as 70-77 seconds. Again long story short… Aetna won’t cover the machine, I have to pay out of pocket. Hey Aetna… Ranger Lead The Way… I putting the word out… word is you SUCK!!

  2. Since my husband’s unsuccessful knee replacement surgery, we have found out that our large employer-sponsored medical insurance covers NO DMEs or prosthetics or orthotics. He needs wheelchair, fit-to-measure leg brace and now motorized wheelchair. No dice. And, apparently, there is NO insurance coverage that I can buy on my own to help with these expenses. He is not yet 65 — two more years.

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