ORIGINAL MEDICARE
Millions rely on Medicare to cover ostomy supplies and thankfully Medicare coverage of ostomy supplies is available to beneficiaries.
Seniors 65 and older use the federally funded health-insurance program to cover most of their medical costs. As most live on a fixed income, having coverage for healthcare needs is important.
Depending on the type of insurance and what provider you use will determine the cost of care. Remember to talk to your doctor or Medicare agent at any time you have questions about your coverage options.
Every year beneficiaries have a chance to re-evaluate their needs for health care services and supplies. New health circumstances may arise, Medicare helps cover costly amounts.
Without coverage, ostomy supplies may run anywhere from $300-$600 each month. For most, that is not an affordable out-of-pocket expense.
Does Medicare Cover Ostomy Supplies
Medicare covers medically necessary ostomy supplies
Medicare provides coverage for prosthetic devices, durable medical equipment (DME), orthotics and supplies also known as DMEPOS. Ostomy supplies are prosthetic devices according to Medicare.
Medicare Part B pays for 80% of allowable charges for supplies, including ostomy supplies. Although, beneficiaries must first pay the Part B deductible amount. The need for ostomy supplies must be due to specific procedures. Including, ileostomy, urinary ostomy surgery, or a colostomy.
Individuals risk paying a higher cost when receiving ostomy supplies that are from a provider who doesn’t accept Medicare assignment. Suppliers who don’t participate in Medicare may also charge higher for supplies.
Beneficiaries must use both providers and suppliers that accept and participate in a Medicare assignment to avoid paying higher for services/supplies.
Linda needs ostomy bags and supplies relating to her condition. Although this is only for temporary use, Linda calls her insurance plan to find a supplier within her network. This kept her costs at minimum and Medicare paid the 80% of allowable charges.
However, Robert wasn’t so fortunate at first. He was unaware his supplier wasn’t accepting Medicare assignment. He had to pay more than twice the amount he should have.
Although, he quickly gave his plan a call and found a supplier within his network. Now, Robert pays 20% of allowable charges after his plan pays its portion.
What are Ostomy Supplies
The National Institutes of Health (NIH) reports that an ostomy is a surgical procedure. This procedure creates an opening which is known as a stoma. The stoma goes from an organ or system within the body – to the outside of the body.
Stomas may be permanent or in some cases temporary depending on a patient’s condition. Ostomy supplies are necessary to collect bodily wastes for all ostomies. The U.S. National Library of Medicine states that supplies may include scissors, stoma powder, skin wipes, pouch clip, and paper towels.
Let’s use Linda’s situation as one example of the temporary use of ostomy supplies. Linda had an infection requiring her bowels to need a temporary rest.
Linda’s healthcare provider performed a temporary “loop colostomy”. During this procedure, a hole was cut into the side of the colon. Then a certain hole in the wall of the abdomen creates an opening known as a stoma.
Thus, creating a way for her stool to drain from the stoma into a bag or pouch that her healthcare provider attaches to the abdomen.
Once Linda was clear of infection this procedure was easily undone by detaching the colon from the wall of the abdomen. Then, the stoma was closed by Linda’s healthcare provider. Allowing the normal flow of stool through the colon.
However, Robert needs a colostomy requiring permanent ostomy supplies. Robert suffers from cancer requiring the removal of the rectum. After surgery, Robert needs a permanent ostomy bag to allow his stool to drain.
In this case, Robert’s medical condition requires him to always use ostomy supplies. Since it’s medically necessary for treating his condition – Medicare may cover 80% of the costs.
Alternative Medicare Options for Ostomy Supplies Coverage
Original Medicare is one way to get benefits for supplies. Beneficiaries receiving inpatient care have coverage under Part A. Outpatient services and supplies are under Part B coverage. Although, certain restrictions may apply.
Marie receives her coverage for health care services through a Medicare Advantage plan (Part C). Private insurance companies that Medicare approves, offer Advantage plans to beneficiaries. Plans must include all the same benefits that Medicare offers.
Advantage plans may include several bonus benefits such as routine vision, dental and/or hearing care. Prescription drug coverage is often part of Part C plans too. Original Medicare plans don’t offer coverage for prescriptions.
Medicare Supplements Can Help Cover the Cost of Ostomy Supplies
Individuals needing ostomy supplies or services should have a well understanding of what they need and how to explain it. This will allow for an easy process when using an agent to determine the best option for coverage.
For example, Linda needs temporary ostomy supplies. So, she calls an insurance broker to find an Advantage plan to enroll in, for help with costs.
Linda was told the plan she chose would cover all her needs. However, her copayments were very high for her ostomy supplies.
The broker never told Linda that she has special rights under federal law within 12 months of joining. These rights allow her to buy a Medigap plan after returning to Original Medicare – if she is unhappy with her Advantage plan.
Fortunately, Linda called a Medicare Agent at FAQ who was able to point her in the right direction. Her agent gave her different options and went over rates and coverage to ensure Linda had the best coverage, that also fit her budget.
If you still have questions about your coverage, give us a call at the number above. Our agents are happy to help with no additional cost to you. You can also fill out an online rate comparison form to discover the best rates in your area.
