Newsroom · Sioux Falls

Medicare Durable Medical Equipment in Sioux Falls 2026: What Part B Covers, What You Pay, and How to Close the 20% Gap

Part B pays 80% of your walker, wheelchair, CPAP, or glucose monitor — with no ceiling on the 20% you owe under Original Medicare.

Big Sioux Benefits Data Desk

Published July 15, 2026 · 10 min read · Sourced from CMS.gov & CDC

Medicare's durable medical equipment benefit quietly covers some of the most consequential purchases a senior makes — walkers, wheelchairs, CPAP machines, and blood glucose monitors — but the 20% you owe under Original Medicare has no annual ceiling. For Sioux Falls' 39,532 Medicare beneficiaries in Minnehaha County, understanding how that cost-sharing works — and how Medigap or Medicare Advantage changes it — is the difference between a manageable expense and a surprise bill.

Every figure below comes from real federal sources: the CMS 2025 Medicare Parts A & B cost-sharing fact sheet, the CMS Medigap standardization guide, the CMS PY2026 plan landscape, and CDC PLACES 2023 county health data. No invented numbers.

What Medicare calls "durable medical equipment"

To be covered as DME under Part B, equipment must meet four CMS criteria: it must be durable (withstands repeated use), medically necessary (prescribed by a treating physician), used in the home (not just in a clinical setting), and primarily medical in purpose (not primarily for comfort or convenience). A walker that keeps a patient with arthritis safely mobile meets all four; a stair-lift motor typically does not, unless medically prescribed.

The scope is broad. Common items Part B covers as DME include walkers, manual wheelchairs, power mobility devices, CPAP and BiPAP machines, home oxygen equipment, blood glucose monitors, test strips, lancets, continuous glucose monitors (CGMs) for insulin-treated patients, hospital-grade beds, trapeze bars, and many orthotics and prosthetics. The 2026 coverage roster follows the same Part B framework as prior years — the rules are stable federal statute.

Source: CMS 2025 Medicare Parts A & B Premiums and Deductibles (Fact Sheet); CMS DME benefit coverage policies (CMS.gov).

The Part B cost math: 80% paid, 20% owed, no cap

Here is the number that matters most: under Original Medicare, Part B pays 80% of the Medicare-approved amount for covered DME after you meet the $257 annual Part B deductible. You owe the remaining 20%.

That 20% sounds manageable until you price real equipment. A power wheelchair may carry a Medicare-approved cost of several thousand dollars. A CPAP machine for the 13-month rental-to-own period adds up. Home oxygen equipment billed over a 36-month rental cap has a substantial approved amount. The 20% coinsurance under Original Medicare has no annual out-of-pocket ceiling — unlike Part D, which now carries a hard $2,100 cap. Without a Medigap plan or a Medicare Advantage plan with an OOP maximum, your DME exposure is theoretically unlimited.

A second cost risk: if a DME supplier is enrolled in Medicare but does not accept assignment, they can charge up to 15% above the Medicare-approved amount. You would owe both the 20% coinsurance and the 15% excess charge — a combined 35% of the approved cost. Only Medigap Plan G covers both gaps.

Why Minnehaha County's health profile makes DME exposure real

The local chronic-condition rates from CDC PLACES 2023 show why DME is not a fringe issue in Sioux Falls — it is a mainstream Medicare cost for a significant share of the 39,532 beneficiaries in Minnehaha County:

Source: CDC PLACES: Local Data for Better Health, County 2023 (2023), Minnehaha County adults.

Source: CDC PLACES: Local Data for Better Health, County 2023 & CMS DME coverage policies.

Work through the math: 37.4% obesity translates directly to elevated sleep apnea risk — and CPAP therapy is the most commonly prescribed DME item nationwide. 22.9% arthritis is the leading driver of walker and wheelchair need among Medicare beneficiaries. 10% diagnosed diabetes means roughly 3,953 of the county's Medicare beneficiaries likely need blood glucose monitors covered under Part B. COPD (5.6%) and coronary heart disease (5.5%) are the two conditions most often triggering home oxygen therapy. These are not edge cases — they describe your neighbors.

Mobility equipment: walkers, wheelchairs, and power chairs

For the 22.9% of Minnehaha County adults with arthritis, mobility aids are often the first DME encounter with Medicare. A walker requires a doctor's order documenting medical necessity — the bar is relatively straightforward. A power wheelchair or motorized scooter carries a higher threshold: CMS requires a face-to-face examination with the treating physician, a written order, and documentation that the beneficiary cannot safely ambulate within their home without the device.

Part B covers both at 80% after the $257 deductible, using the Medicare-approved fee schedule. A Medicare-approved supplier is required, and for power mobility devices CMS applies prior-authorization rules — the supplier must obtain approval before delivery or you risk a denied claim. Sanford USD Medical Center (5★ CMS hospital quality rating) and Avera McKennan Hospital (4★) both have affiliated rehabilitation departments that can initiate the mobility evaluation and order process through the Sioux Falls care continuum.

Respiratory equipment: CPAP and home oxygen in Sioux Falls

With 37.4% of Minnehaha County adults classified as obese by CDC PLACES 2023, obstructive sleep apnea (OSA) — and its first-line treatment, CPAP therapy — is among the highest-frequency DME needs in the Sioux Falls market.

Medicare Part B covers CPAP machines when a sleep study documents OSA meeting CMS diagnostic criteria and a physician writes the order. The equipment is delivered on a rental basis: Part B pays 80% of the approved monthly rental amount for 13 months. After the 13th month, ownership transfers to the beneficiary, and consumables (masks, tubing, filters) continue to be billed under Part B supply allowances.

Home oxygen is the other major respiratory DME category. It is covered when a physician documents that blood-oxygen saturation falls at or below the CMS threshold (generally ≤88% at rest, on exertion, or during sleep). Oxygen equipment — concentrators, portable units, or liquid oxygen — is rented for up to 36 months, after which the supplier continues to be paid for maintenance and consumables. Part B pays 80% throughout; the 20% you owe accumulates month over month unless a Medigap plan or Advantage OOP cap absorbs it.

For the 5.6% of the county's adults with COPD and 5.5% with coronary heart disease, home oxygen is a real and recurring budget item — not a one-time purchase.

Diabetes equipment: blood glucose monitors and CGMs

10.0% of Minnehaha County adults have diagnosed diabetes — approximately 3,953 of the county's 39,532 Medicare beneficiaries. For them, the Part B DME benefit delivers two important tools:

• Blood glucose monitors (BGMs): Part B covers the monitor, test strips, and lancets for any beneficiary with diagnosed diabetes. The treating physician must order the supplies. Most pharmacies and durable medical equipment suppliers stock BGM supplies; confirm the supplier is Medicare-enrolled.
• Continuous glucose monitors (CGMs): Part B covers CGM systems — receiver, sensors, transmitters — for beneficiaries with diabetes who are treated with insulin and meet additional CMS clinical criteria. CGMs entered Part B coverage after years of Part D-only access, and for insulin-using patients they can substantially reduce the burden of finger-stick testing while keeping glucose data current for the treating physician.

One important split: insulin itself (and related injectables) is generally covered under Part D, not Part B. In 2026, Part D-covered insulin is capped at $35 per month per covered product, and the broader Part D out-of-pocket ceiling is $2,100. These two cost pools — Part B for the monitoring equipment, Part D for the drugs — are separate. A beneficiary managing diabetes needs to understand both limits to build an accurate annual budget.

How to close the 20% DME gap: Medigap vs. Medicare Advantage

The 20% Part B coinsurance applies to every covered DME claim. Under Original Medicare alone, that exposure has no annual ceiling. The two paths to protection are Medigap (Medicare Supplement) plans and Medicare Advantage (Part C) plans. They work differently:

Source: CMS — Choosing a Medigap Policy (Publication 02110) (CMS Publication 02110), standardized per 42 CFR §403.205.

Medigap Plan G is the widest DME net for beneficiaries first eligible for Medicare after January 1, 2020 (the new-enrollee standard): it covers 100% of Part B coinsurance — meaning the 20% DME gap — and Part B excess charges if your DME supplier does not accept assignment. You pay a monthly Medigap premium; in exchange, your DME (and all Part B) cost-sharing is essentially zero after the annual Part B deductible.

Medigap Plan N covers Part B coinsurance but does not cover excess charges — meaning if your supplier charges above the Medicare-approved amount, you're responsible for the 15% excess. Plan N typically carries a lower monthly premium than Plan G, making it a reasonable trade-off for beneficiaries who verify their suppliers accept assignment.

Under Medicare Advantage, the five standard PPOs in Minnehaha County must cover DME at least as generously as Original Medicare, and they add an annual out-of-pocket maximum that caps total cost-sharing — including DME — for the plan year. The premium structure differs: the 2026 local PPO landscape includes two plans at $0 premium alongside higher-premium options.

Source: CMS Medicare Advantage / Part D Landscape (PY2026) & CMS Medicare Advantage & Part D Star Ratings (2026), Minnehaha County.

The trade-off between Medigap and Advantage for DME-heavy users: Medigap Plan G delivers the most predictable out-of-pocket DME cost (essentially zero after the Part B deductible), but at a higher monthly premium. Medicare Advantage PPOs add a yearly cap on all cost-sharing, but cost-sharing on individual claims — including DME — varies by plan and requires in-network supplier use for the best rates. For a beneficiary who expects recurring DME needs (monthly CPAP supplies, quarterly CGM sensors, or ongoing home oxygen), the plan-year OOP maximum is the critical number to compare, not the monthly premium alone.

The supplier assignment question: protect yourself before you order

One DME cost risk that catches beneficiaries off guard: not all Medicare-enrolled suppliers accept Medicare assignment. A supplier who does not accept assignment can charge up to 15% above the Medicare-approved amount — and you are responsible for both the 20% coinsurance and the 15% excess charge. The combined exposure can reach 35% of the Medicare-allowed cost for expensive equipment.

The practical steps to protect yourself:

1. Ask before you order. Before a supplier delivers any major equipment, ask: "Do you accept Medicare assignment?" A yes means they accept the Medicare-approved amount as payment in full (minus your 20%). A no is a warning sign to shop further or confirm your Medigap plan covers excess charges.
2. Verify supplier enrollment. Only Medicare-enrolled suppliers can bill Part B for DME. Using a non-enrolled supplier means Medicare will not pay — at all — and you would owe the full cost.
3. Use Medicare's Supplier Directory. Medicare.gov maintains a searchable directory of enrolled and assignment-accepting DME suppliers by ZIP code. Cross-referencing your Sioux Falls supplier before ordering is a five-minute check that can prevent a significant bill.
4. For power mobility: get the paperwork in order first. The face-to-face exam, clinical documentation, and prior authorization must precede delivery. A supplier who tells you to order now and sort the paperwork later is a risk — not a service.

What to watch for 2026

1. Review your plan's DME cost-sharing annually. Medicare Advantage plans adjust their Evidence of Coverage each plan year. If you have an Advantage plan and expect DME needs in 2026, review the new EOC for changes to DME cost-sharing tiers or supplier network requirements — changes take effect January 1.
2. CGM eligibility is expanding. CMS has been broadening CGM coverage criteria. If you have diabetes and were previously told you did not qualify for a CGM under Part B, check again with your physician — eligibility criteria have evolved.
3. Track your Part B deductible reset. The Part B deductible resets each calendar year. If you order DME in late December, you'll face another deductible in January. For recurring equipment needs, timing deliveries to earlier in the calendar year can reduce the double-deductible risk.
4. Verify Sanford or Avera network DME suppliers for Advantage plans. Sioux Falls' two major health systems — Sanford (5★ CMS) and Avera McKennan (4★ CMS) — both operate affiliated DME supplier networks. Confirming that your equipment supplier is in your Advantage plan's network for 2026 before ordering avoids out-of-network cost-sharing surprises.
5. Check the Part D–Part B split for new diabetes devices. As insulin delivery technology evolves (hybrid closed-loop systems, combination CGM/pump devices), some components are covered under Part B and some under Part D. When adopting new technology, confirm which benefit covers each component before filling a prescription or ordering equipment.

How we know all this: Big Sioux Benefits runs every article through a data desk that cross-references the CMS Part B and DME coverage framework, CMS plan landscape, CMS star ratings, CMS Hospital Compare, CMS Medigap standardization rules, and CDC PLACES local health data — built and maintained by Strategic AI Architects. Every figure is from a published federal dataset. This article is education, not advice; confirm your specific coverage, equipment qualifications, and supplier status with a licensed agent or Medicare.gov. We take no payment from any carrier or supplier to feature or favor them.