Overview

Durable medical equipment (DME) is an essential component of standard medical treatment for the member's exclusive use. It is prescribed or authorized by the participating physician as a treatment for illness, disease or injury. DME serves a medical purpose, withstands repeated use and fulfills basic medical needs, as opposed to satisfying personal preferences regarding style and range of capabilities.

Ownership of DME Items

DME items may be rented or purchased. If rental is more expensive than purchase for long-term use, purchase is recommended. Health Net follows Medicare guidelines for ownership of DME items, which state members who rent certain types of DME own the equipment after paying copayments for the item for 13 months. There are other types of DME that members will own after paying copayments for the item for a specified number of months. There are also certain types of DME for which members will not acquire ownership no matter how many payments they make for the item while a Health Net member. A member's previous payments towards a DME item when they had Original Medicare (Part A and Part B) do not count towards payments made while a member of a Health Net plan.

Repairs

Repairs to equipment a member has purchased or already owns prior to Health Net membership are covered when necessary to make the equipment serviceable. Repairs to equipment purchased under Health Net coverage are also covered. Repair or replacement due to misuse or loss is not covered.

Apria Healthcare is the exclusive provider for DME services for membership capitated to Apria. Membership not included under DME capitation should still be referred to Apria as they are the preferred vendor for DME. Diabetic supplies (chemstrips and lancets) are also considered DME items for Health Net members.

Capitation is applicable to certain membership assigned to select participating physician groups (PPGs) only. The Division of Financial Responsibility (DOFR) allows a PPG to participate in DME capitation. If DME is Health Net or shared-risk, and is part of Health Net's current capitation agreement with Apria Healthcare, Inc. and E-Medical Supplies, a referral to Apria or E-Medical Supplies does not require authorization from Health Net or the PPG. Refer to the member's Evidence of Coverage (EOC) for plan-specific information.