Catheterization is a medical procedure that involves the insertion of a thin, flexible tube into the bladder through the urethra. It can be done by an individual using intermittent self-catheterization or after a surgery, where an indwelling catheter is kept in place for a few days to aid in recovery. Intermittent self-catheterization is more commonly used to manage urologic conditions, such as urinary retention, urinary incontinence, or even bladder and kidney cancers. The type and severity of a urologic condition that requires catheterization can also differ depending on the patient's age, gender, and medical history. However, if you need to use them, their cost can be a little nerve wracking. To help ensure your quality of life remains high and your urologic conditions are treated, here’s how to get intermittent catheter supplies through managed Medicaid plans.
What to Know About Urinary Catheters
Urinary catheters are medical devices used to manage urinary retention, incontinence, or other types of urologic conditions. They’re inserted through the urethra and into the bladder to allow urine to flow out. Catheters can be used for short-term or long-term periods, depending on the underlying medical condition.
There are several types of catheters available, each designed for a specific purpose. One of the most common types is intermittent catheters. These are typically used to help drain the bladder. Alternatively, Foley catheters are used for longer periods—they tend to stay in place for a few days or weeks at a time. However, Foley catheters need to be inserted by a healthcare professional while intermittent catheters can be inserted at home. There are several types of intermittent catheters including straight tip and coudé tip, red rubber, latex, silicone, closed system catheters, and hydrophilic catheters. Your doctor will work with you to find the right type of urinary catheter for your needs.
Important Information Regarding Medicaid
Medicaid is a joint federal and state program that provides health insurance to low-income individuals and families, as well as people with certain disabilities. Although the program is primarily funded by the federal government, each state has its own eligibility criteria, benefits, and administration. This means that you’ll need to adhere to different rules and processes for coverage depending on where you live.
Medicaid operates through a network of healthcare providers, including doctors, hospitals, and clinics, who are reimbursed for their services by the program. Some states use managed care plans, which contract with healthcare providers to provide services to Medicaid enrollees.
To qualify for Medicaid, individuals must meet income and asset requirements, which vary by state. Eligibility is primarily based on income, but factors such as family size, disability status, and age also play a role. Once an individual is deemed eligible, they receive a range of health care benefits, which can include doctor visits, hospital stays, prescription drugs, and more. In some cases, Medicaid may also cover long-term care services, such as nursing home care. If your doctor deems them medically necessary, catheters can also be covered under Medicaid.
Overall, Medicaid plays an important role in providing healthcare coverage to vulnerable populations, including low-income individuals, pregnant women, children, and people with disabilities. However, some families who fall below the poverty line may still not qualify for Medicaid plans, so always work with a representative to maximize your coverage options and find the right insurance plan for your needs.
More on Medicaid Managed Care Plans
Managed Care is an additional health care delivery system that’s meant to help manage cost, utilization, and quality. It provides Medicaid health benefits and other services through contracted agreements between managed care organizations (MCOs) and Medicaid agencies. This helps states lower Medicaid program costs while maximizing the utilization of health services. Medicaid managed care therefore leads to an improvement in the overall health plan performance, health care quality, and outcomes. Some states have more initiatives than others, so make sure that you familiarize yourself with your coverage offers prior to ordering any supplies. The following are some examples of these types of plans.
Health Maintenance Organization (HMO)
One example of a type of managed care plan is an HMO. HMOs require individuals to consult with a primary care physician within the network of approved doctors and limits coverage for providers outside of the network. However, HMOs do cover 100% of preventive care and are usually more affordable. The affordability is limited by the lower degree of flexibility.
Preferred Provider Organization (PPO)
A Preferred Provider Organization (PPO) offers you the flexibility to visit any doctor, regardless of their affiliation with the network. However, it may be less expensive to see an in-network provider. You are not usually required to obtain referrals from a primary care physician for outside consultations. PPOs also cover most preventive care, however, due to the flexibility they offer, PPOs tend to be more expensive.
Point of Service (POS)
Point of Service (POS) plans combine features of HMOs and PPOs, offering you the ability to see both in and out-of-network doctors. However, your costs will be higher than with an HMO. You may also be required to see a primary care physician in order to receive a referral for an out-of-network doctor. The goal of a POS plan is to provide options while still managing to keep costs lower.
Exclusive Provider Organization (EPO)
EPO plans also offer a combination of features found in HMOs and PPOs. You’re not required to see a primary care physician or get a referral, similar to a PPO. However, you may need to see in-network doctors to be covered, similar to an HMO. The cost of an EPO plan usually falls in between an HMO and a PPO.
Understanding the Managed Medicaid Guidelines for Catheter Coverage
If you have a medical condition that requires catheterization, out of pocket costs can quickly add up. Since intermittent self-catheters can only be safely used once, you’ll likely need several per day to maximize your quality of life. This can get quite expensive, which is why most Medicaid plans will cover several different catheter supplies. All you need to do is make sure that you’re eligible and provide the appropriate documentation to receive your insurance covered catheter supplies.
If you’re not sure about what your state’s plan coverage includes, you may want to work with your doctor or a reputable medical supply company to get answers. This can help streamline the ordering process and ensure that you provide all of the necessary documentation needed for coverage. This usually means that you’ll need confirmation from your doctor, in the form of medical history, documentation regarding your diagnosis, and a prescription. Oftentimes, your insurance provider can be billed directly to simplify the process.
When it comes to proving that catheters are essential to your treatment, Medicaid may differ in their requirements. Like Medicare, doctor’s notes usually need to provide specific details, including the permanence of the condition, a detailed diagnosis, and the frequency of use for urology supplies. To establish permanence, doctors must indicate that without catheters, the patient cannot manage their disease, making catheters necessary for ongoing quality of life. Diagnosis must align with Medicaid’s approved list of conditions and the doctor's notes must specify how many times per day or week a patient needs to self-catheterize.
Trying to navigate the insurance process when dealing with your urologic supplies can be confusing, but it doesn’t mean that you should give up hope. Managed Medicaid plans do provide a degree of coverage, especially when catheters are deemed medically necessary. To help you along the way, Byram Healthcare is available. As one of the leading medical supply companies in the country, we work with Medicare, Medicaid, and most private insurances to help you navigate the intricate process of obtaining insurance-covered urologic products. Byram provides a better patient financial experience because we’re in-network with over 260 million covered lives. This translates to lower co-pays and deductibles. Learn more about our mission or browse our urology product catalog today.
Byram Healthcare is a member of the National Association for Continence’s Trusted Partners Program, whose mission is to provide quality continence care through education, collaboration and advocacy. We continue to build partnerships in the clinical community to ensure we focus on what’s best for the patient.
