“I have Medicare. Does Medicare cover ostomy supplies? How much do they cost? Where do I buy them? How does it all work?”
These questions are very common. While you’re busy preparing or recovering from surgery, it’s easy to miss these key pieces of information.
The short answer is, yes, Medicare covers the majority of the cost of ostomy supplies if you meet certain conditions.
Read on and we’ll explain these conditions in more detail so you have the knowledge to get the ostomy supplies you need while maximizing your Medicare coverage.
How do I get my ostomy supplies?
Before we dive into how your insurance works with your medical supplies, let’s talk about how you can get your supplies in the first place!
For Medicare to cover ostomy supplies, you need to order them from a medical supply company, like Better Health.
The medical supply company will help you set up an account. The medical supply company will ask for:
- Information about you, such as your name, address, and contact details
- Your Medicare insurance information and secondary insurance coverage (if you have it)
- Your ostomy supplies prescription (typically your doctor will fax this information directly to your medical supply company but you may need to let your doctor know where to send it)
- What supplies you’d like to order
How does Medicare coverage apply to ostomy supplies?
Ostomy supplies are covered by Medicare Part B. Under Medicare guidelines (and for most other insurers) ostomy supplies fall into a category known as durable medical equipment.
Durable medical equipment is defined as:
- Durable (can withstand repeated use)
- Used for a medical reason
- Not usually useful to someone who isn’t sick or injured
- Used in your home
- Must be prescribed by your doctor
Generally, Medicare Part B pays for 80% of ostomy supplies. You have to meet the Part B deductible and must have had colostomy, ileostomy, or urostomy surgery.
How do I find out if something is covered by my insurance?
If you’re not sure what ostomy supplies your insurance will cover, Better Health can help.
Better Health insurance experts can help you understand your Medicare coverage, explain which supplies are covered, and help you anticipate out-of-pocket costs. Call us at 1-415-475-8444.
Are there other Medicare options that will cover ostomy supplies?
Yes. While Medicare Part B is the primary coverage for ostomy supplies, Medicare Part C can help cover costs, too.
Medicare Part C is an optional part of Medicare that lets you to purchase secondary insurance coverage. The secondary coverage is provided through private, Medicare-approved insurance companies.
Part C might cover the rest of your supply costs that are not covered by Part B. This means that Medicare Part B covers 80% of your supply costs and Part C covers the other 20% – which means you might have pay nothing out-of-pocket for your ostomy products.
While it’s an additional cost, purchasing Medicare Part C might be a good option for you if you need to order ostomy supplies. The cost to purchase Medicare Part C might be less than the ongoing out-of-pocket expense from just using Part B.
Are there differences in how Medicare and private insurance providers cover ostomy supplies?
Private insurance typically works much the same way as Medicare.
You’ll need to choose a medical supply company and provide them information about yourself and your insurance.
From there, your supply company will work with you to determine your coverage. Once you’ve been approved, you can order supplies.
Which ostomy supplies does Medicare typically cover?
Medicare covers ostomy supplies such as:
- Ostomy skin barriers
- Ostomy pouches, including drainable or closed pouches
- One-piece and two-piece ostomy systems
- Skin protectant wipes and sprays
- Barrier rings and strips
- Barrier pastes
- Adhesive removers
- Barrier extenders
- Ostomy belts
- Irrigation supplies
- Night drainage tubing and receptacles
What ostomy supplies does Medicare not cover?
- Ostomy wraps and other support garments (unless ordered by a prescription)
- Ostomy bag covers
- Ostomy underwear
Many ostomy wraps, bag covers, and underwear are sold by third-party websites, which do not accept insurance. You’ll need to pay for them out-of-pocket.
What is the amount of supplies I can order?
Typically, Medicare guidelines let you order supplies in 30-day or 90-day amounts. When you first order supplies or if you’re trying out new supplies, we recommend getting a 30-day supply — if the products don’t work out or if you need something different, you won’t have a ton of extra supplies on hand.
Keep in mind that you’ll need to find a place in your home where you can store supplies. Ostomy products need to be stored in a cool, dry place away from humid environments like bathrooms.
If you do find yourself with an overabundance of supplies and don’t have room to store them, consider donating them to a local ostomy support group. Support groups can redistribute to community members who may need supplies but can’t afford them.
What if I need more supplies?
It’s very common for someone to have a period where they use more than the average amount of ostomy supplies. These cases include:
- Immediately post-surgery, when the body is adapting to its new anatomy and output levels are high
- Stoma changes, when stomas grow, recede, or retract and create a need for different barriers
- Skin problems, when irritated, abraded skin interferes with barrier adhesion
If you need more supplies than the Medicare-approved amount, it’s likely you’ll need to pay out of pocket for those supplies.
In some cases, it’s possible to petition Medicare and request that they cover the extra supplies. Your medical supply company should be able to help you with that process.
Extra ostomy supplies
The good news is that there are alternatives for sourcing extra supplies.
As a patient at the hospital you can ask for help from nursing staff, wound care ostomy nurses, and social workers. They can help you navigate the complexities of setting up a medical supplier.
At home, your home health nurse, outpatient ostomy clinic, or social worker can help you set up your supplier.
How much will I pay out of pocket?
Unfortunately, the answer is complicated because it depends on a lot of factors. With standard Medicare, you’ll pay the following:
|Your Part B monthly premium||A premium is a monthly charge for all Part B services, such as doctor visits and supplies. In 2020, this is $144.60 or higher, depending on your income.|
|Your Part B deductible||A deductible is the amount you pay for services before insurance begins to pay. In 2020, the standard amount is $198.|
|Your Part B copay||Once your premium and deductible are met, Medicare typically pays 80%of the Medicare-approved amount of your ostomy supplies.|
You are responsible for the remaining 20% co-pay.
If you have a Medicare Advantage plan (aka Medicare Part C), your co-pay may be less because your plan covers a high percentage of the cost of your ostomy supplies.
What steps can I take to make sure I get the supplies I want?
This is a great question! Many people know ahead of time that they will be having ostomy surgery. If you’re part of this group, you should have the opportunity to review ostomy samples and select a medical supplier ahead of time.
You can order your supplies before surgery. The first time you order, we recommend ordering a month’s supply of barriers, bags, and other support items.
The are several reasons to limit your order to one month of supplies:
- You discover post-surgery that the supplies you ordered don’t match your needs
- You don’t like the product
- You need something different, such a convex barrier
- Your skin has a reaction to certain barriers or products
- Your ostomy may change while healing
By limiting the amount of your first order, you can avoid having too many products that you can’t use or store.
Sometimes ostomy surgery is unexpected. If your situation keeps you from setting a medical supply company ahead of time, your caregiver can support you by contacting a supply company while you recover from surgery. Hospitals will supply ostomy products while you are an in-patient and will send you home with a variety of samples.
Regardless of the timing of your surgery, it’s vitally important to ensure you set up your ostomy supply arrangements as soon as possible. There’s no worse feeling than being down to your last few barriers and bags, especially if you need frequent changes.
I’ve seen ostomy supplies for sale from places like Amazon and eBay. Are those supplies okay to use?
We don’t recommend it. With Better Health, ostomy supplies come directly from the manufacturer. This means Better Health guarantees that the supplies are temperature protected and have not expired. Products from third-party sellers may be old, expired, or exposed to high temperatures so they may be in poor condition and will not work properly.
Why should I choose Better Health as my supplier?
Better Health will work with you to maximize your coverage and ensure your out-of-pocket costs are the lowest they can be. Our team of experts will ensure that you understand your benefits and can help you figure out ways to reduce your out-of-pocket costs. We’re also more than happy to make recommendations and offer guidance for products that meet your individual ostomy needs.
Give us a call at 1-415-475-8444 to get started today.