What You Need to Know
- The procedure creates an opening in the abdomen called a stoma.
- People with stomas need special equipment to collect bodily waste.
- Getting Medicare to pay for ostomy products is increasingly difficult.
It’s estimated that anywhere between 750,000 to 1 million people have ostomies in the United States, a surgical procedure used to treat diseases of the digestive or urinary systems that creates an opening on the abdomen called a stoma.
The stoma connects from one organ to the outside of the body and can either be permanent or temporary depending on a patient’s condition. These individuals rely on durable medical equipment (DME) to collect bodily waste from all ostomy procedures, making access to ostomy supplies extremely important.
Yet, it’s increasingly difficult for patients to get the supplies they need because the margins on ostomy products are low and are extremely complicated. Most providers will not accept assignments, which would mean the patient would have to pay upfront and bill Medicare themselves or shop around where their provider choices are extremely limited.
In the event they can get a provider with a product, most likely they will be unable to give the patient the exact product they need due to low margins. Instead providers will push them to a different product that does not meet their highly individualized need, which may cause complications.
This issue expands beyond Medicare because Medicare Advantage plans typically reimburse a percentage of Medicare. Sometimes members will switch to a Medicare Advantage plan unaware of these challenges and are left without the product/provider who is able to get them the supplies they need.
What Does Medicare Cover?
Medicare typically will provide coverage for prosthetic devices, a category that ostomy supplies fall under but will only be covered for specific procedures including a urinary ostomy, ileostomy surgery or a colostomy.
Medicare Part B, which is considered the medical portion of Original Medicare and includes coverage for services that are preventative, covers 80% of charges for ostomy supplies. It is required for beneficiaries to pay the Part B deductible first unless they have additional coverage.
Although Medicare covers 80% of charges for ostomy supplies, most are not aware that they must sign up for Medicare Part B insurance when they first become eligible and could end up being deterred because of additional premiums that are due. With ostomy supplies ranging from $300 to $600, these premiums aren’t cheap.
What Is the Medicare Limit on Ostomy Supplies?
With a prescription from a doctor and a supplier that is contracted with Medicare, Medicare will cover up to a three-month supply of ostomy products at a time. However, Medicare does not cover everything and under Medicare Part A, which is hospital coverage, so many are left with deductibles and other cost-sharing.