Under the Affordable Care Act, many insurance plans are required to cover a range of essential services, such as hospitalizations and prescription drugs. But durable medical equipment isn’t among them, except for breast pumps, which most plans must cover.

These days, insurers often contract with selected medical supply companies to provide equipment, just as they negotiate rates for other services. But patients often don’t realize that, said Alice Bell, a physical therapist and senior payment specialist at the American Physical Therapy Association, a professional group. Patients who don’t use an insurer’s preferred provider may be charged a higher rate or have to pay the entire amount out-of-pocket, she said.

“It’s important to make sure the supplier is in-network, even if the doctor prescribes it, because it varies,” Bell said.

When Bruce Lee, 48, strained a ligament in his left leg, his doctor prescribed a walking boot and gave him a list of medical suppliers. The doctor warned Lee to make sure he chose one in his insurance network.

.
Medpage Today
.

Still, “it boggled my mind that they were allowed to bill her, because she never saw anyone from there,” Wickizer said.

Whatever the arrangement, the key for the patient is to find out whether whoever is supplying the equipment is in their insurance network and how much they’ll owe out-of-pocket.

Insurers might approve coverage of medical equipment only if a provider certifies it’s medically necessary. Even with a doctor’s OK, approval isn’t assured. The “fancier” a piece of equipment is, the more challenging it is to get an insurer to agree that it’s medically necessary, said Dr. Angela Gardner, who practices in Dallas and is a past president of the American College of Emergency Physicians.

“In general, for a commercial [insurer], basic crutches will be covered, forearm crutches are partially covered, and hands-free crutches won’t be covered,” she said, referring to a crutch that attaches to the injured leg and allows someone to move around without relying on their hands or arms.

Yet for some patients, shopping for such equipment is not an option. They need it on the spot or, like Harnett, are unable to get around well enough to go somewhere to buy it. If the patient can wait, many medical device suppliers deliver equipment to the home, or many devices can be purchased online.

Opting not to use insurance

Beyond weighing in- and out-of-network options, patients have an option on durable medical equipment they don’t typically get when choosing medical services: buying over the counter.

This might prove significantly cheaper than using an insurance plan. A pair of standard armpit crutches, for example, may cost at the local pharmacy, while the insurance copayment might be 0.

“A savvy consumer will look at the copay and see whether or not they need to use their insurance,” said Gardner.

Sometimes the prices insurers agree to pay for durable medical equipment are significantly higher than the price online or at the drugstore. That differential can be important if someone has a high-deductible plan and owes the entire amount.

An orthopedist suggested that Barbara Barrall, of Medford, N.J., replace her simple knee brace with a hinged model that could bend. When the bill arrived, Barrall’s daughter, Cynthia B. Sosnowski, thought the ,400 charge must be a mistake. She went online and found the identical brace for between and at sporting goods and medical supply stores.

But when she called the orthopedist’s office, the woman said there was no mistake. That was the amount the doctor was allowed to charge the insurer. When Sosnowski called the insurer, she was told not to worry: Her mother’s share of the charge was just 5; the rest was covered by a retiree employer plan.

Sosnowski wasn’t placated. “This is why insurance is so expensive in our country,” she said. She has filed a grievance with the insurer to protest the charge.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

.
.
.
.