PATIENT INSURANCE GUIDE

Using Insurance for Medical Equipment: A Patient’s Guide

A brace, cold therapy device, CPM machine, compression device, or other prescribed item can raise unfamiliar questions: Will insurance cover it? What will I owe? What happens after my clinician sends an order? This guide walks through the process in plain language.

Start here: An insurance benefit, an approval, and a final paid claim are different steps. We can help review the order and available benefits, discuss an estimate, and explain what information is still needed.

The process, from prescription to final bill

1. Your clinician recommends equipment. Ask what item you need, why, and when you need it. Your clinician sends an order to Medequip.
2. We review the referral. Medequip reviews the requested item, your contact and insurance details, network status, and whether the plan calls for prior authorization.
3. We discuss coverage and estimated cost. The estimate depends on the plan’s rules, allowed amount, deductible, copay or coinsurance, and what has already been applied toward your benefits.
4. We coordinate the equipment. We explain the applicable fitting, shipment, delivery, or rental and return arrangements.
5. The claim is processed. After the item is supplied, the insurer may issue an Explanation of Benefits (EOB) showing how it processed the claim. The EOB is not a bill.

For more on the handoff and equipment setup, see our Patient Education page.

“Covered” does not mean no out-of-pocket

An item may be a covered benefit and still leave you with a deductible, copayment, or coinsurance. Your share is commonly based on the plan’s allowed amount, rather than the supplier’s listed charge (the billed amount). Your costs may also differ if a supplier is out of network, the item does not meet the plan’s medical-necessity criteria, or you choose a noncovered option.

Example, for illustration only: Suppose an in-network item has a $600 allowed amount, you have $200 left on your deductible, and the plan then pays 80% of the remaining covered amount. You pay $200 toward the deductible plus 20% of the remaining $400 ($80), for an estimated $280. This assumes the item is covered, no separate copay applies, and there are no other plan rules. The actual amount may change when the claim is processed.

Five terms that make the estimate easier to understand

Deductible: The amount you pay for covered services before the plan starts paying under its deductible rules. Some benefits work differently, so ask how the DME or orthotic benefit applies.

Copayment (copay): A set dollar amount for a covered item or service, if your plan uses one.

Coinsurance: A percentage of the allowed amount that you pay for a covered item, often after the applicable deductible.

Allowed amount: The amount your plan recognizes for the item. It is used to calculate plan payment and your share; it may differ from the supplier’s charge.

Charge (Billed) amount: The amount Medequip places on the claim to the insurer for a specific HCPCS code. This amount does not impact how much the insurance agrees to pay for an item, and does not impact your potential out-of-pocket amount.

Out-of-pocket maximum: On plans with this limit, the most you pay in a plan year for covered services subject to the limit. Covered, in-network deductible, copay, and coinsurance payments generally count. Premiums, noncovered services, and some out-of-network costs generally do not. Confirm what applies to your plan; Original Medicare has different cost rules.

Why a “covered code” may still not cover your item

Insurers use billing codes, including HCPCS codes, to identify equipment. When calling your insurer, a representative may confirm that a specific HCPCS code appears in your benefits. That answer alone does not establish that the item qualifies for payment by your insurance for your diagnosis, surgery, or clinical circumstances. The insurer may require documentation, an in-network supplier, or prior authorization. Even with those things, the item may not be paid for by your insurance because your insurance does not cover that item for your diagnosis, or the surgery you are having.

We explain this distinction in detail, with a knee CPM example, in Why a covered DME code may still lead to a denied claim.

Questions to ask before the item is delivered

1. What is the exact item and billing code, if known? Is it covered for my diagnosis and procedure?
2. Is Medequip in network for my specific plan? If not, what out-of-network benefits or alternatives apply?
3. Is this item a purchase or rental? If rented, how long is it covered, when does billing start, and how do I return it?
4. What is the allowed amount and my remaining deductible, copay, coinsurance, and out-of-pocket balance?

If you call your plan, write down the date, representative’s name, and reference number. Ask for the coverage policy or written benefit details when the answer is unclear.

Can I use an HSA or FSA? What if I need more time to pay?

HSA/FSA: Many eligible, unreimbursed medical expenses, including qualifying equipment and patient cost shares, can be paid or reimbursed with health savings account (HSA) or flexible spending arrangement (FSA) funds. Eligibility depends on the item and your account rules. Check with your plan or account administrator, keep the order and itemized receipt, and do not seek reimbursement twice for the same amount.

Payment plans: If the expected out-of-pocket amount is difficult to pay at once, ask Medequip about a payment plan. We can discuss available arrangements for your situation before you commit to the item.

What if I do not have insurance, or decide to self-pay?

Ask us for a price estimate for the specific item and whether it is a purchase or rental. If you are uninsured or choose not to use insurance, we can provide you with an expected out-of-pocket amount.

A self-pay decision may affect whether spending counts toward your health plan’s deductible or out-of-pocket limit. Check with the plan before deciding.

After delivery: EOBs, bills, and denials

Is an EOB a bill? No. It is your insurer’s explanation of how it handled the claim. Compare the EOB’s patient responsibility with any Medequip bill. Contact us with any questions.

What if the claim is denied? Find the denial reason on the EOB or letter and contact both Medequip and your insurer. Sometimes a missing record or coding issue can be addressed; other decisions may require an appeal. In most circumstances, Medequip can take care of this for you.

When should I contact Medequip? If a statement does not match what you expected, your insurance changed, you have a rental return question, or you need to discuss a payment arrangement, contact us with your order or account details.

Ready to talk through your order?

Tell us what your clinician prescribed and when you need it. We can explain the referral process, what information is missing, and the next step for a cost discussion.

See the patient order process and request contact · Review our insurance network information · Contact Medequip