Durable medical equipment
Most HMSA plans cover durable medical equipment (DME). Examples of covered DME include oxygen equipment, hospital beds, mobility assistive equipment (wheelchairs, walkers, power mobility devices), insulin pumps, and breast pumps.
A covered DME item must be prescribed by a provider and must meet all of the following criteria:
- It is FDA-approved for the purpose being prescribed.
- It is durable enough to withstand repeated use.
- It is primarily used to serve a medical purpose.
- It is appropriate for use in the home, which is where you live and does not include a hospital or skilled or intermediate nursing facility.
- It is necessary and reasonable for the treatment of your illness or injury, or to improve the functioning of a malformed body part. It should not be useful to a person in the absence of an illness or injury.
- For mobility equipment, the DME is used to help a patient in daily living activities such as toileting, feeding, dressing, grooming, and bathing in a patient’s home.
Please refer to your Guide to Benefits to see if DME is a benefit of your plan and to learn more about this benefit.
Repair, replacement, and supplies
In general, HMSA follows Medicare criteria when determining coverage for supplies and replacement parts. As a member, you will need to request supplies or repairs when needed from your DME provider.
Repair and replacement of your equipment and supplies or accessories are covered, but are subject to certain limitations and exclusions, such as:
- Typically, payment is not made for equipment that is replaced within five years of the date of purchase.
- Repair of equipment that has not been maintained according to the owner’s manual will not be covered. You are responsible for the cost to repair damage due to misuse or abuse.
- If your doctor prescribes equipment that is the same or similar to equipment purchased earlier, HMSA may deny coverage for the equipment because it is a duplicate. For example, if you received a gel pressure mattress and four months later purchased a powered pressure-reducing air mattress even though the first mattress was in good condition, HMSA may deny coverage for the second mattress.
Certain equipment requires prior approval, or precertification, before it will be covered. Please read Submitting a precertification request and HMSA’s DME medical policies for information on the precertification process. We encourage you to ask your doctor or contact HMSA’s Customer Relations department to find an HMSA-participating DME supplier who will obtain precertification on your behalf.
HMO members may require referrals and administrative reviews
If you are an HMO member, certain DME items may require a referral from your primary care provider (PCP) or health center to be eligible for benefits. If needed, your provider will obtain approval for a DME supplier to provide your equipment. If your PCP refers you to an out-of-state or nonparticipating DME supplier, your PCP will need to submit an administrative review to HMSA before you purchase the DME. HMSA will only approve an out-of-state or nonparticipating provider if there is no appropriate participating DME supplier in Hawaii that can provide the same equipment.
Please also read Durable medical equipment (DME): Renting, buying, and buying online for more information.