Durable Medical Equipment (DME) 101
The process of acquiring certain types of durable medical equipment (DME) — especially when funding through Medi-Cal — can be lengthy, arduous, and sometimes infuriating. One of our Undivided parent members, Lelah Coppedge, says the absurd amount of work she has had to put into procuring her child’s wheelchair has made her feel like “a CEO of a Fortune 500 company.” And she is far from alone in feeling that way, as many of us can empathize with based on our own experiences with DME companies.
To demystify and troubleshoot the oftentimes frustrating DME procurement process, we spoke to Coppedge, whose child relies on DME to live their best life; Lisa Concoff Kronbeck, Undivided’s Public Benefits Specialist; and Leslie Lobel, Undivided’s Director of Health Plan Advocacy.
What is durable medical equipment?
Durable medical equipment refers to medical supports and devices that can withstand repeated uses over time. Common types of DME covered by Medi-Cal covered by Medi-Cal include:
- Mobility aids such as wheelchairs and scooters (manual and motorized)
- Ambulation devices such as canes, walkers, and gait trainers
- Hospital beds and accessories including bedside rails and mattresses
- Oxygen and respiratory equipment such as oxygen racks and tanks, ventilators, nebulizers, and CPAP machines
- Patient lifts and standing systems such as stairway chairlifts and standing frames
- Portable ramps
- Blood glucose monitors
- Infusion pumps
- Bathroom equipment such as seats, benches, stools, rails, and shower hoses
- Augmentative and Alternative Communication (AAC) technologies such as speech-generating devices
- DME that helps caretakers with disabilities (including biological parents, stepparents, foster parents, and legal guardians) care for their child
If the specific DME your child needs isn’t included in Medi-Cal’s list of covered equipment, you do have options — it is possible to appeal and petition Medi-Cal to cover it if your child’s doctor proves it is medically necessary and provides a prescription.
Note that Medi-Cal explicitly excludes some types of DME from coverage. Those include:
- Air conditioners, air filters, and heaters
- Educational items such as books
- Household items such as food blenders (though companies such as VitaMix and BlendTec offer their products at discounted prices if they are considered medically necessary; consider reaching out to them via email about your child’s needs)
- Modification of cars or other highway motor vehicles
- Orthopedic mattresses and waterbeds, recliners, rockers, seat lift chairs, and other furniture items
- Reading lamps and other lighting devices
- TV sets
- Exercise equipment such as bikes or tricycles (in most cases)
Funding options for durable medical equipment
An “order of operations” exists when it comes to funding medical expenditures such as DME, according to Kronbeck, whose child uses a wheelchair. In this order, private insurance defaults as the first payer, then Medi-Cal and/or California Children’s Services (CCS), and finally Regional Center.
Many of us end up relying on private insurance and/or Medi-Cal to finance our kids’ medical needs. (Though it’s worth noting that it’s possible to get funding for DME through CCS or Regional Center if your child qualifies and your insurance won’t cover the DME.)
- It can withstand repeated uses over time.
- It serves a medical purpose.
- It is prescribed by a doctor and is considered “medically necessary” because of an illness, injury, functional impairment, or congenital abnormality.
- It isn’t useful in the absence of an illness, injury, functional impairment, or congenital abnormality.
- It is appropriate for use inside or outside of the home.
Medi-Cal typically covers the lowest-cost equipment that meets a patient’s medical needs. For example: if your child has the ability to get around using a manual wheelchair, Medi-Cal probably wouldn’t cover a motorized chair since the lower-cost manual option would meet your kid’s medical needs.
Per the funding order of operations, private insurance must pay its share of a DME purchase before Medi-Cal will agree to cover the remainder. For this reason, it’s important to ensure that the DME provider you choose contracts with both your Medi-Cal plan and your private insurance plan. Once private insurance pays its obligation, the DME provider will bill Medi-Cal for the remaining balance (up to the approved Medi-Cal rate for service). When a provider contracts with Medi-Cal, they agree to accept the Medi-Cal-contracted rate for the services or equipment they provide, which means that once Medi-Cal has paid its share for an item they cover, the provider has been paid in full and cannot bill you for any leftover balance for the covered item.
You may be responsible for paying a remaining balance for DME accessories not covered by Medi-Cal, but this should be discussed prior to purchase. For example, if you purchase a wheelchair for your child and request a cup holder and decorative spokes for the wheels, Medi-Cal will pay for the cost of the wheelchair itself, but not for the cup holder and spokes, as they are not considered medically necessary. However, the provider cannot bill you for the chair or medically necessary accessories even if the retail cost is more than the contracted Medi-Cal rate.
- Diabetic testing strips and lancets
- Tracheostomy supplies
- Enteral feeding (tube-feeding) supplies
- Urinary catheters
- Wound care dressings
- Incontinence supplies such as diapers, undergarments, barrier creams, and incontinence washes
Similar to DME, CMS also require a doctor’s prescription, but because they usually cost significantly less than DME, they don’t always require prior authorization. Learn more about how to get single-use medical supplies (and other medical necessities) covered by Medi-Cal in our Medi-Cal Terms & Services Glossary.
Durable medical equipment companies (and their shortcomings)
It’s critical to consider your funding source(s) when choosing which DME company to work with, Kronbeck and Lobel advise.
If you plan on only using private insurance for funding, you are limited to whatever companies contract with your insurer. Reach out to a service representative or check out their website to find out more about the DME coverage.
If you plan on using Medi-Cal as secondary coverage to your primary insurance, the DME company must contract with both your private insurance and your Medi-Cal plan, Kronbeck says. Only two companies currently contract with Medi-Cal: National Seating and Mobility and NuMotion.
According to Roberts, over the last decade, NuMotion and National Seating and Mobility have effectively monopolized the DME industry because of Medicare’s 2011 decision to “abandon set prices [for DME] in favor of ones set by competitive bidding,” journalist Paul F. Roberts wrote in an article published by Mother Jones last year.
“By one estimate, the move reduced the federal government’s costs by 35%,” Roberts wrote. “But at the same time, locally owned wheelchair shops quickly began to disappear as large corporations offered rock-bottom bids to Medicare and private insurers.” In other words, the government prioritized saving money, even though it negatively impacted small businesses and, by default, people with disabilities relying on DME to live their lives to the fullest.
Another issue that has risen in recent years is that private equity firms have bought up DME manufacturers and suppliers and consolidated them to cut costs and maximize returns. Eileen O’Grady, Healthcare Director at the Private Equity Stakeholder Project (PESP), shares in this report that many families' local DME shops are being bought by corporate chains, which means families increasingly face fraudulent billing practices and struggle to access repairs. Many private equity-owned DME suppliers have even challenged right-to-repair legislation, meaning that families have even longer delays in accessing repairs.
The consequences of monopolization in the DME industry
Because of monopolization, understaffed NuMotion and National Seating and Mobility branches across the United States have become overrun by orders for various types of DME — and, as a result, the most in-demand forms of DME (particularly wheelchairs, as Roberts notes in the Mother Jones article) have become exceedingly difficult to procure.
Lobel, whose adult daughter has relied on a wheelchair for mobility her entire life, says the “old system” for DME procurement operated much more efficiently and ethically than the one that has formed in the decade since competitive bidding took hold.
Before competitive bidding, the DME fitting and procurement process tended to be personalized based on an individual’s unique medical and financial needs, Lobel says. Now, it prioritizes saving insurance and DME companies money. She elaborates on the major differences between the old and new DME systems — and their stakeholders — in the video below:
Coppedge says she continued to beg National Seating and Mobility to fix her son’s chair until December — four months after they initially received it. Using an ill-fitting chair for four months straight caused her son to sustain physical injuries including bruising on his lap and lacerations on the back of his head. After experiencing similar issues when she ordered a gate trainer for her son, she gave up. “I said, alright, I’m done with National [Seating and Mobility]. I cannot work with them anymore. Let’s go to NuMotion and see what they have to offer.”
Unfortunately, NuMotion also dropped the ball, despite a hopeful first consultation with one of their representatives. “This guy was great,” Coppedge says. “He spent all this time with us at CCS. He mapped up all this stuff he was going to do. And then when I tried to follow up and I called NuMotion, they were like, ‘We don’t have any record of [your child] in our system. … And [the representative] never called back. He never answered emails. He never answered CCS. They just totally ghosted us.”
It’s hard to not feel demoralized by the current state of the DME industry, Coppedge says.
“Every family I talk to, same story. Everyone’s waiting for parts. It’s really sad … They [National Seating and Mobility and NuMotion] have cornered the market and we’re just stuck. I don’t even know what to do from here. It makes me want to start my own [DME] company. It makes me want to figure out a way that families can work around this issue.”
A spokesperson from National Seating and Mobility wrote in an email that NSM “cares deeply about those [they] serve” and “continues to work alongside other industry and consumer advocacy organizations to passionately advocate for changes to address” the long wait times associated with procuring certain types of DME — particularly complex rehabilitative technologies (CRTs) including motorized wheelchairs.
“Suppliers and clinicians must navigate complicated policies that govern the repair and servicing of those products,” the spokesperson wrote. “The documentation burden and, in many cases, the prior authorization process required to get a wheelchair repair approved is profoundly time-consuming and lengthens the time it takes to service CRT equipment. More streamlined processes are needed to eliminate some of the unnecessary steps that further delay the repair process.”
The spokesperson continued, “Federal, state, and commercial insurance plans’ reimbursement rates don’t cover the costs associated with doing repairs and have not had a notable adjustment to account for inflation in the last decade,” which has led to a shortage of providers in the DME industry.
The NSM spokesperson acknowledged that the company needs to continue working to improve the equipment acquisition and repair processes, despite systemic issues in American healthcare.
“As you can imagine, it is never the goal of a supplier to make the process take longer as completing the repairs in a timely manner is beneficial to both our clients and NSM. We are dedicated to working with our clients and other partners to improve the repair process and are committed to providing quality care for our clients because it is the right thing to do.”
NSM does not, however, support proposed “right-to-repair” laws, which many wheelchair users and disability activists say could significantly alleviate long wait times when it comes to servicing broken or dysfunctional equipment, Roberts wrote in the Mother Jones article. Right-to-repair laws would allow DME users to service their own equipment by whatever means they choose, rather than being forced to wait on NSM or NuMotion for service.
NuMotion did not respond to our request for comment by the time of publishing.
How to maximize your experiences with the DME system
The long waits and poor service experiences that have become synonymous with the DME procurement process are incredibly frustrating, but ultimately unavoidable, given the current state of the DME, medical, and insurance systems in the United States. This, of course, isn’t great to hear, but we have a few tips for navigating and getting the most out of this flawed system.
It’s easy to fall through the cracks of any sort of complex bureaucratic process. As such, it is critical to stay on top of your child’s DME order with proactivity, persistence, and diplomacy, Kronbeck and Lobel agree. “There’s no way to avoid the wait time, but there are ways to be effective while you’re in wait mode,” Lobel says.
To start, obtain the medical documentation required to initiate the DME acquisition process.
“Already have in place a visit with your provider who is going to most likely need to write a prescription [for the equipment],” Lobel says. “In addition to a prescription, you will need a live office visit note [from an in-person appointment with your doctor] detailing the need for an assessment for the specific piece of equipment.”
Next, figure out how DME coverage works with your health plan, Lobel advises. “Do you have a separate deductible for DME? What’s the share of cost between you and the provider for DME? What’s the share of cost for your benefit and is there a benefit maximum? … You’re going to hear it from the DME provider, but knowing it for yourself and understanding what that means is important.”
It’s also important to ascertain if you will need prior authorization from your insurer before they agree to cover the cost of your kid’s equipment. Medi-Cal always requires prior authorization for DME (as primary or secondary coverage), and many private insurers do as well.
Throughout the process, make sure to do anything the DME provider asks of you in a timely fashion, Lobel advises. “Have the ball in their court as often and as soon as you possibly can. Ask the DME provider to tell you what the next step is so that you can be working on the next step while they’re dealing with the step you’ve just delivered.”
Kronbeck suggests monitoring the status of your order on your DME provider’s patient portal to stay on top of the process. You can find NuMotion’s portal here and National Seating and Mobility’s here. The portals should tell you not only where in the process your order currently resides, but also expected completion dates for every step and details about what’s going on behind the scenes. You can ask your DME provider if there is anything you can do — such as nudge your insurance company, for example — based on the information provided by the portal.
“It may just be that watching it is like watching an ant walk a mile, but it's nice to be on top of things and know where things stand — even if you don't have control over it,” Kronbeck says. “Because you never know when there's a step where you could potentially look into something or find out what the hold up is.”
Whenever you communicate with the DME provider, be sure to ask them to acknowledge your correspondence, and keep your tone as professional and courteous as possible. “You always have to remember that when you’re advocating for your child,” Lobel says.
Additionally, when a technician comes to fit your child, ask them lots of questions about the equipment in question, such as:
- Why will this type of equipment best suit my child’s needs? Tell me about comparable options on the market and why you recommend this specific option.
- Are there other equipment options we should consider? Why or why not?
- Do other customers seem satisfied with this option? Why or why or why not?
- Will this equipment need any modifications to best suit my child’s needs? Why or why not?
- What types of equipment modifications do you recommend? Why?
- How will you ensure the equipment fits my child and suits their needs when it arrives?
- Does this equipment typically hold up well over time in your experience?
- How long does it typically take to acquire the type of equipment my child needs? Does it tend to work well for most of your clients right off the bat, or does it require adjustment? How long does the adjustment process typically take?
- How long have you been working in the DME industry? What do you like about your job?
If you don’t feel satisfied with the technician’s answers, follow up with providers from your child’s care team. Ask them for their opinions on the technician’s recommendations and relay their input to the DME provider.
“That's a place where families are pushed and they don't even know it,” Lobel says. “They're pushed in the direction of the equipment that the national provider wants to sell, or it’s the easiest to sell. And it may be right for their child and it may not, but they won't know unless they ask.”
Tips for accessing DME while you’re in wait mode
If your child is without equipment while waiting for their DME order to process, Coppedge, Kronbeck, and Lobel recommend leveraging the power of your local community, both in-person and online.
“Talking with other people who have similar issues — with other parents, with other people — can be really empowering,” Kronbeck says. “What works for this family might not work for your family, but it can still be very informative.” Chatting with fellow parents can also be helpful going into your child’s first DME appointment.
If your child is without equipment while waiting for their order to be processed, consider asking parents of your child’s classmates if they have any comparable equipment they’re not using anymore that you could borrow in the meantime. You could also post a request in or browse Facebook equipment exchange groups such as California Special Needs Equipment Buy/Sell/Trade or Affordable Durable Medical Equipment for Seniors & Disabled.
Also consider checking out California-based DME exchange and donation groups such as Triumph Foundation, Cecily’s Closet, The ReCARES Network, California Assistive Technology Reuse Coalition, or the Maryam Parman Foundation For Children, which provides medical equipment, supplies, and services for children whose health insurance denies coverage.
The road to obtaining DME can be trialing depending on your child’s needs, health coverage, and the DME companies themselves. But if you are providing the DME company and insurance the documents they need to keep the process moving along, know that you are doing everything you can given our country’s flawed medical system. If you need more help, Undivided Navigators and public benefits and insurance experts can work with you to find a solution to your child’s needs.