TRICARE Coverage for Durable Medical Equipment

Joe Wallace

TRICARE provides insurance coverage for durable medical equipment (DME) when a care provider says the equipment is medically necessary.

This benefit applies to those enrolled in TRICARE Prime, TRICARE Select, and TRICARE For Life. Do you or a loved one covered under TRICARE need DME? To qualify for coverage, the equipment must withstand repeated use, serve a medical purpose, and be appropriate for use in the home.

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TRICARE Coverage for Durable Medical Equipment

Durable medical equipment coverage is available to active duty service members, their families, and military retirees. Beneficiaries must obtain a prescription from a TRICARE authorized provider to receive coverage for the DME, and the prescription must show the equipment is medically necessary. This is determined in three ways:

• The equipment must help a body part function better or prevent a condition from worsening.
• It must help the patient function as well as possible.
• Finally, the equipment must deliver the appropriate level of performance and quality for the patient’s specific condition.

Without a prescription that meets these clinical standards, TRICARE will not pay for the equipment.

Plan Variations and Costs

For TRICARE Prime, out-of-pocket costs are considered minimal when using network providers. TRICARE Select beneficiaries typically pay a cost share after meeting their annual deductible.

TRICARE For Life beneficiaries in the United States and U.S. territories must follow Medicare rules for obtaining equipment, and TRICARE acts as the “second payer” in these cases.

Beneficiaries should consider using suppliers that participate in Medicare to reduce their costs. If Medicare covers the equipment, TRICARE generally pays the remaining patient responsibility, and if a beneficiary lives overseas, TRICARE becomes the primary payer for durable medical equipment.

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Repairs and Replacements

TRICARE may cover the repair of durable medical equipment that is owned by the beneficiary. Routine maintenance is only covered when the manufacturer requires a professional to perform the service and may include technical tasks like cleaning internal components or testing specialized machinery.

Replacement of equipment is permitted under limited circumstances; this may be covered if the patient’s physical condition changes. It may also be covered if the equipment is damaged accidentally and the repair cost exceeds its replacement cost. If the equipment stops working and cannot be repaired, it is eligible for replacement. A new prescription is required for all replacement items.

TRICARE does not cover equipment with “deluxe” or so-called “luxury features.” If a patient chooses an item with extra features that are not medically necessary, they must pay the difference in price. For example, if a patient wants a high-performance wheelchair when a standard model meets their medical needs, the additional costs are the patient’s responsibility.

Items Excluded From Coverage

Some items are excluded from the durable medical equipment benefit under TRICARE. There is no coverage for non-medical equipment such as humidifiers, air cleaners, or smart watches. Exercise equipment such as stationary bikes is also excluded, considered general use rather than strictly medical.

TRICARE will not pay for equipment if the same item is available for free at a military hospital or clinic where the beneficiary is enrolled. If a patient is currently in a hospital or skilled nursing facility, the facility is responsible for providing the necessary equipment. TRICARE also prohibits the coverage of duplicate items. A beneficiary cannot receive two identical pieces of equipment for different locations.

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