There are roughly 100,000 ostomy surgeries in the US every year, and regardless of whether they're temporary or permanent, they save lives. However, many people don't expect to use ostomy supplies during their lives, so trying to navigate insurance coverage at first can be a little overwhelming. In addition to learning about how to care for your stoma and peristomal skin and adjusting to life with an ostomy, it's important to make sure you have access to affordable ostomy care. Whether you have private health insurance, Medicaid, or Medicare, there are a few things you should know. To help, we've put together a comprehensive guide on how to navigate insurance coverage to access the ostomy supplies you need without spending thousands of dollars.
Understanding Your Medical Needs for Ostomy Care
Before getting into too much detail about what your insurance plan covers, it's important to grasp the basics of ostomy care and understand your specific medical needs. Ostomies can vary in type, such as colostomy, ileostomy, or urostomy, and each requires different ostomy supplies and care routines.
A colostomy is a surgical procedure that involves creating an opening, or stoma, in the abdominal wall through which a portion of the colon (large intestine) is redirected to the skin's surface. An ileostomy creates a stoma by diverting a section of the small intestine, specifically the ileum, to the abdominal wall. Finally, a urostomy redirects the urinary system, typically the ureters, to create a stoma. The ostomy needs for each surgery can vary, but they will all require the use of an ostomy pouching system. Other ostomy supplies you may need include skin barriers or wafers, adhesives, ostomy belts, and products to maximize peristomal skin health. Although it can be overwhelming initially, your doctor or ostomy nurse is available to help you adjust to living with an ostomy, so don't be afraid to ask questions as needed.
Important Insurance Terms to Know
To effectively navigate the complex world of insurance, it's important to familiarize yourself with some key terms. These can help you better understand what the insurer is responsible for and what out-of-pocket costs you may incur.
- Premium — The premium is the regular fee you pay to maintain your insurance coverage. This is a recurring cost that you need to budget for.
- Deductible — The annual deductible is the amount you need to pay out of pocket before your insurance coverage kicks in. Understanding your deductible is essential, as it can significantly impact out-of-pocket expenses.
- Co-pay — A co-pay is a fixed amount you pay for specific medical services or prescriptions. Knowing what you'll need to pay for ostomy supplies can help you plan your expenses more effectively.
- Coinsurance — Coinsurance refers to the percentage of the total cost you're responsible for after reaching your deductible. It determines your cost-sharing with the insurance company.
- In-network — In-network healthcare providers, hospitals, and suppliers have agreements with your insurance company to provide services at a negotiated rate. This typically results in lower out-of-pocket expenses for you.
- Out-of-network — Out-of-network healthcare providers, hospitals, or suppliers are not covered by your insurance plan's agreements. Services or supplies from out-of-network providers often come with higher costs, so it's important to stay in-network whenever possible.
There are also a few different insurance plan types to be aware of. Some of the most common include Point of Service plans (POS), Preferred Provider Organization (PPO), and Health Maintenance Organization (HMO) plans.
Are Ostomy Products Covered by Insurance?
Ostomy supplies are generally covered by insurance, but the extent of coverage can vary depending on the insurance plan. In most cases, your plan will cover supplies such as ostomy bags, wafers/barriers, adhesive products, and accessories. However, it's essential to know the specifics of your health insurance coverage and understand any limitations. If, for some reason, your insurance policy doesn't cover the full costs of your ostomy needs, your doctor may recommend supplemental insurance.
Choosing an Insurance Plan
Selecting the right insurance plan is another significant step in ensuring you have access to affordable ostomy products. While you might already have insurance coverage for ostomy care, if you don't have an active plan or sufficient coverage, you'll want to take the time to review your options. To help, consider the following insurance plans available.
Private Insurance Plans
There are a wide variety of private insurance plans available to you through different companies. Although most private insurance plans offer coverage for ostomy supplies, there are some stipulations about pre-existing conditions. However, private companies are still required to act within healthcare laws set out by the Affordable Care Act, so you cannot be denied coverage if you have a pre-existing condition. The important thing to remember with private plans is that premiums, deductibles, copays, and other costs can vary greatly based on the provider. To help you find the best plan for your needs, talk to your doctor or ostomy nurse. They can give you more information about plans best suited to your healthcare needs.
Medicare
Medicare is a federal health insurance program that provides coverage for eligible individuals 65 years or older, as well as certain younger people with disabilities such as ostomies. Medicare typically provides coverage for ostomy supplies under Medicare Part B, with some exceptions. However, Medicare coverage for ostomy supplies isn't always 100%. In some instances, Medicare will pay 80%, and you'll pay 20%. There is also a maximum number of supplies that will be covered each month. Typically, coverage includes:
- Up to 20 drainable pouches
- Up to 60 closed pouches
- Up to 20 skin barriers
- 150 adhesive remover wipes every 3 months
- 1 ostomy belt
- 1, 4 oz. tube of skin barrier paste
- 150 protective barrier wipes every 6 months
- 10 oz. of protective powder every 6 months
Medicare requires a prescription for supplies to be covered, which can be written by your doctor. Within the prescription, there should be documentation about how many supplies you'll need for a month. Medicare Advantage (Medicare Part C) can also help you improve your quality of life as an ostomate as it offers more coverage options and health services.
Medicaid
State Medicaid programs are another option for qualifying individuals. Medicaid is a joint federal and state program that provides health insurance plans to low-income individuals and families, as well as people with certain disabilities. While it's partially funded by the federal government, each state has its own requirements and eligibility, which may impact which ostomy supplies are covered. Medicaid Managed Care plans can also help individuals who need certain types of medical treatment or care. Unlike Medicare plans, the allowable amounts of ostomy products and supplies through Medicaid depend on state guidelines. More information on these differences can be found here.
Supplemental Insurance Policies
Although the Affordable Care Act made it easier for individuals with disabilities to gain access to insurance coverage, some plans may not be enough. If you need additional health care or coverage, you may want to consider looking at your options for add-on policies. For example, there are options that will cover the remaining 20% if the costs of your ostomy supplies aren't completely covered by Medicare.
How to Find High-Quality Ostomy Medical Supplies
After finding the right insurance plan for your needs, the next step is to order your high-quality ostomy medical supplies. Many new ostomates get recommendations from their doctors, but don't be afraid to order a few different types of supplies to try them out for yourself. Whether your insurance covers ostomy supplies completely or partially, ordering from a reputable medical supply company can help you save time, money, and stress. Byram Healthcare is a proud ostomy supplies provider offering easy, hassle-free ordering options. Our team of specialists can help you with the ordering process to ensure you get your ostomy supplies discreetly delivered to your doorstep.
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.
