An ostomy is a lifesaving surgical procedure that substantially improves symptoms and makes day-to-day life more enjoyable. However, caring for an ostomy requires several supplies—from ostomy pouches and wafers to skin adhesive removers and cleansers. Over time, the cost of these supplies can add up, making it difficult for long-term sustainability. Luckily, several types of insurance, including Medicare, offer coverage for eligible individuals. For more information, here's everything you need to know about Medicare coverage for ostomy supplies.
Does Medicare Cover Ostomy Supplies?
Yes, Medicare Part B (medical insurance) covers medically necessary ostomy supplies for individuals who have had a colostomy, ileostomy, or urostomy. However, Medicare will only cover the number of supplies your doctor prescribes based on your condition, and there are limits to the quantity of durable medical equipment (DME).
Medicare Part B also only covers about 80% of the cost of each medical supply order for ostomates, so there are still out-of-pocket expenses that you may need to plan for. To get 100% coverage, you may need to take out a supplemental insurance policy through Medicare (Medigap) or an additional replacement plan. In doing so, you may be able to reduce the amount of personal expenses and get your ostomy products 100% covered. You can find more information about Medicare-related supplemental plans here.
How to Determine Eligibility for Medicare Insurance Coverage for Ostomy Supplies
Several criteria must be met to qualify for Medicare coverage of ostomy supplies. Here's what you need to know:
Doctor’s Progress Notes — Medicare requires your doctor to document your need for ostomy supplies in your medical record. This documentation must include details about your condition, such as the type and location of your ostomy and the specific supplies needed to manage it effectively.
Signed Prescription — A valid prescription must be signed and dated by your doctor. The prescription should include:
- The type of ostomy supply
- The quantity needed
- A statement of medical necessity
Medicare-Approved Supplier — Ensure you order from a supplier enrolled in Medicare and possessing a Medicare supplier number. Only approved suppliers can bill Medicare on your behalf.
Local Coverage Determination (LCD) — Medicare has specific guidelines, known as LCDs, that outline what is considered "reasonable and necessary." Ensure your doctor’s notes and prescription align with these standards.
To ensure coverage, individuals must also meet all other applicable Medicare statutory and regulatory requirements.
Remember, Medicare insurance differs from private insurance plans, so it's important to make sure that you adhere to the procedures of your specific policy to get your insurance-covered ostomy supplies. You can learn more about insurance options and ostomy care here.
What is the Allowable Quantity of Medicare-Covered Ostomy Supplies per Month?
Individuals with active Medicare coverage may receive a certain amount of monthly ostomy products. The maximum quantity of supplies covered by Medicare insurance varies based on the item. Still, all require a prescription from your doctor and a related doctor's progress note, as explained above. Your doctor will work with you to determine the number of ostomy supplies you need based on your circumstances, but the following are allowable quantities covered by Medicare:
- Drainable (can be one- or two-piece systems) ostomy pouches — up to 20
- Closed ostomy pouches — up to 60
- Urostomy pouches — up to 20
- Pediatrics ostomy pouches — up to 20 (60 for two-piece mini closed pouches)
- Irrigator sleeves — up to four
- Stoma caps — up to 31
- Ostomy belt — one
- Skin barrier with flange — up to 20
- Adhesive remover wipes — 150 every three months
- Skin barrier paste — one, 4oz. tube
- Stoma lubricant — one, 4oz. tube
- Protective barrier wipes — 150 every 6 months
- Protective powder — 10oz. every 6 months
These numbers reflect the current Medicare coverage at the time of this article's publishing. Please keep in mind that coverage may change over the years. You can find the most up-to-date information about individualized supplies, insurance codes, and their monthly coverage here.
What is Not Covered by Medicare?
Typically, Medicare does not cover ostomy-related products used solely for convenience. They must be medically necessary. Therefore, you likely won't be able to obtain any non-medical accessories or anything used for personal convenience and management of an ostomy.
Supplies exceeding the limits are unlikely to be covered without medical justification and pre-approvement. According to Medicare's Local Coverage Determination (LCD) policy, the allowable number of products has specific determinants. Their policy states:
“The quantity of ostomy supplies needed by a beneficiary is determined primarily by the type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma. There will be variations according to individual beneficiary needs, and their needs may vary over time. The actual quantity needed for a particular beneficiary may be more or less than the amount listed, depending on the factors that affect the frequency of barrier and pouch change.
The explanation for the use of a greater quantity of supplies than the amounts listed must be clearly documented in the beneficiary’s medical record. If adequate documentation is not provided when requested, the excess quantities will be denied as not reasonable and necessary.”
Therefore, it is possible to get more ostomy supplies than what's "allowed" in Medicare Part B coverage, but only if your provider clearly outlines the reasoning with supporting historical documentation.
Finally, ostomy supplies purchased from non-Medicare-approved suppliers may void the coverage benefits, and you may receive a bill to pay for 100% of the cost. That's why ensuring you only order from reputable medical supplies that work with Medicare is important.
How to Find the Right Medical Supplier for Ostomy Products
To ensure you're getting the most out of your Medicare plan, it's important to only order your ostomy supplies from a legitimate medical supply company. Byram Healthcare is proud to be a Medicare-approved supplier with hundreds of different ostomy supplies available for order.
As a Medicare provider, Byram Healthcare must comply with the rules set by CMS (Centers for Medicare & Medicaid Services), and we cannot provide medical supplies when Medicare denies a claim. If you're having problems or are unsure if your transition to Medicare has been completed, please contact the Medicare Benefits Coordination & Recovery Center at (855) 798-2627.
Byram Healthcare is committed to doing our part to improve the lives of those living with ostomies through convenient product delivery and a diverse ostomy product catalog. We work with Medicare, Medicaid, and most private insurance companies to help you get the most out of your healthcare plan. At Byram, we strive to provide a better patient financial experience because we're in-network with over 260 million covered lives. This translates to lower co-pays and deductibles. Contact us today to get started with your order or if you have any questions about our products.
