Medical Equipment That is Always Covered by Insurance

Goals

To identify medical equipment that is always covered 100% by medical insurance coverage when prescribed by physicians for purposes of developing products for prospective patients.

Early Findings

Preliminary research indicates that breast pumps may be the only durable medical equipment that is required to be covered at 100%. All other covered durable medical equipment appears to be subject to copays, deductibles, and coinsurance as determined by individual insurance plans.

BREAST PUMPS

  • The Affordable Care Act (ACA) mandates that "breast pumps are 100% covered for all insurance plans that begin after August 1, 2012." However, insurance companies can place restrictions on which products are covered.
  • As Healthcare.gov states: "Your health insurance plan must cover the cost of a breast pump. It may be either a rental unit or a new one you’ll keep. Your plan may have guidelines on whether the covered pump is manual or electric, the length of the rental, and when you’ll receive it (before or after birth)."

DME THAT REQUIRES FACE-TO-FACE ENCOUNTERS

  • The ACA also put restrictions who can prescribe some durable medical equipment, which will impact telemedicine:
  • "Section 6407 of the Affordable Care Act established a rule requiring a face-to-face encounter with the Medicare beneficiary (including the use of Medicare-approved methods of telehealth) as a condition of payment for certain items of DME. In addition, these items of DME must have a written order prior to delivery."
  • The ACA mandates this face-to-face encounter for "155 items covered under the face-to-face requirement."
  • The most updated list of DME that requires a face-to-face encounter can be found here.

AETNA'S DME COVERAGE

  • Aetna's list of ambulatory assist devices that it covers can be found here. In general, with a doctor's prescription and diagnosis, Aetna will cover:
    • Canes
    • Crutches
    • Standard Walkers
    • Pediatric Walkers/Crawlers
    • Prone, Supine and Upright Standers for Children with Special Needs
    • Heavy-Duty Walkers
    • Kneeling Walkers
    • Leg Extensions
    • Walking Belts
    • Gait Trainers
  • Aetna covers compression garments, non-elastic binders, or individually fitted prescription graded compression stockings for individuals who have been diagnosed with the following:
    • Lipodermatosclerosis
    • Stasis dermatitis (venous eczema)
    • Varicose veins (except spider veins)
    • Venous edema
    • Venous ulcers (stasis ulcers)
    • Edema accompanying paraplegia, quadriplegia, etc.
    • Edema following surgery, fracture, burns, or other trauma
    • Lymphedema
    • Post sclerotherapy
    • Post-thrombotic syndrome
    • Postural hypotension
    • Prevention of thrombosis in immobilized persons
    • Severe edema in pregnancy

MEDICARE'S DME COVERAGE

  • Medicare covers the following durable medical equipment, but only at 80% after a member's deductible has been met:
    • "Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
    • Blood sugar monitors
    • Blood sugar (glucose) test strips
    • Canes
    • Commode chairs
    • Continuous passive motion (CPM) machines
    • Crutches
    • Hospital beds
    • Infusion pumps and supplies
    • Manual wheelchairs and power mobility devices
    • Nebulizers and some nebulizer medications
    • Oxygen equipment and accessories
    • Patient lifts
    • Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
    • Suction pumps
    • Traction equipment
    • Walkers"
    • "Orthopedic shoes only when they’re a necessary part of a leg brace
    • Arm, leg, back, and neck braces
    • Artificial limbs and eyes
    • Breast prostheses (including a surgical bra) after a mastectomy
    • Ostomy bags and certain related supplies
    • Urological supplies
    • Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease"
    • "Cataract glasses
    • Conventional glasses or contact lenses after surgery with insertion of an intraocular lens
    • Intraocular lenses"
  • A complete list of covered medical supplies for Medicare can be found here, but again, none of it is covered at 100%, as Medicare benefits pay at 80% after the patient has met his/her deductible.

UNITEDHEALTHCARE'S DME COVERAGE

  • UnitedHealthcare's list of covered durable medical equipment is here.

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