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Costs Associated with Ostomy Supplies
How much you pay will depend on whether or not you have Part B coverage and where you buy your equipment. In general, if you are enrolled in Medicare Part B:
- You will pay 20% of the approved Medicare amount, after you have paid your yearly deductible.
- You will pay less if you buy from a supplier who accepts assignment. Participating suppliers will not charge more than the Medicare-approved amount.
- You may owe little to nothing, if you receive your Medicare through a Medicare Advantage Plan, depending on the plan with which you have signed up and your benefits with the plan.
- You may owe little to nothing if you have a Medigap/Medicare Supplemental policy.
It is important to do your homework. Read about the factors that affect how much coverage you will receive. Make sure all paperwork is completed correctly and that you buy your supplies through an approved supplier that accepts assignment.
How Much Will Medicare Cover For Ostomy Supplies?
The regional carrier in your area decides the amount of supplies you may order each time. The quantity of supplies needed by each person is decided by the type of ostomy, its location, its construction and the condition of the skin around the ostomy. Medicare may approve increased supplies if those supplies are deemed medically necessary by your doctor.
To get approval for increased supplies, your doctor must carefully and completely document the reasons for the need. For example: chemotherapy has caused skin damage and the ostomy is leaking more than usual. There is no guarantee that Medicare will approve a greater quantity of supplies, but good documentation will help with approval.
If you receive your Medicare through a Medicare Advantage Plan (like an HMO or PPO), there may be additional benefits and other criteria for ordering your supplies. Make a point of checking with your health plan's customer service department before ordering your supplies.
Qualifying For Ostomy Supplies Coverage
You must have Medicare Part B coverage and your doctor must have documented your need for the supplies in your medical records. The doctor must also write you an order (prescription) for the supplies clearly stating which supplies you will need. Your doctor will know what is necessary to qualify for the type of supplies prescribed for you. You are allowed up to a three-month supply at one time. Ostomy supplies are covered for people with a:
Medicare may cover (depending on your individual needs):
- Pouches (1-piece, 2-piece, locking, drainable, closed)
- Skin barrier wafers
- Eakin Cohesive (T) Seals
- Barrier wipes
- Adhesive remover
- Deodorant drops
- Belts (appliance)
Where to Buy Ostomy Supplies?
You will save money on your ostomy supplies if you order from a Medicare-approved supplier. Suppliers must meet strict standards to qualify as a Medicare supplier and will have a Medicare supplier number. You may also buy your supplies from any store that sells them. However, if the supplier from which you order your ostomy supplies is not enrolled in Medicare, Medicare will not pay for them.
Things you should think about before you choose a supplier:
- There are two types of Medicare suppliers: participating suppliers, and those who are enrolled but have chosen not to participate.
- Participating suppliers will not charge more than the Medicare allowed amount.
- Medicare-approved suppliers who do not want to participate can charge more than the Medicare-approved amount. However, they cannot charge more than 15% above the Medicare-approved amount. They may also ask you to pay the entire bill when you pick up the supplies. In this situation Medicare will send the reimbursement directly to you. Be prepared to wait; it may take a couple of months to receive payment.
- If you receive your Medicare coverage through a Medicare Advantage Plan (like an HMO or PPO), it is likely that the plan will have its own steps for equipment purchases. In addition, the plan may have restrictions on the supplier from which you can buy. It is important to know that your health plan must supply at least what Medicare covers -- they cannot supply less. Depending on your plan you may actually receive more coverage than you would get with Medicare alone. It is wise to call your Medicare Advantage Plan's customer service and ask about your coverage before you order any ostomy supplies.
Will Medicare Pay For My Ostomy Supplies?
Medicare will cover most of the cost of ostomy supplies if you have a condition that requires them. To ensure that Medicare pays for your ostomy supplies, you must follow the steps below:
- Only your doctor can prescribe the supplies for you, so do not order anything until you have visited your doctor, no matter what the sales person tells you.
- The doctor must document your need for ostomy supplies in your medical records and give you a signed and dated order (prescription) for them.
- The supplier must receive the order before Medicare is billed and it must be kept on file by the supplier.
- If you receive your Medicare through a one of Medicare Advantage Plans (like an HMO or PPO) it is likely you will have to follow the plan's steps for approval and purchase. Make a point of calling your plan's customer service number and ask about their steps for coverage for ostomy supplies.