Does Medicaid Cover Ostomy Supplies?
- Does Medicaid cover ostomy supplies? Find out how Medicaid and Medicare ostomy supply coverage works, who's eligible and where to get additional help.
If you have an ostomy, ostomy supplies are essential for maintaining your health and hygiene. However, not all insurers and health care plans cover ostomy supplies even though they're medically necessary. If you need ostomy supplies, it's helpful to understand what help is available to manage the costs. Below, you can find out whether Medicaid, Medicare and private health care insurance pay for ostomy supplies and who qualifies.
Does Medicaid Cover Ostomy Supplies?
Medical supplies like ostomy supplies aren't a mandatory Medicaid benefit, which means that states can choose whether to cover ostomy supplies for their beneficiaries. As of 2018, a KFF survey found that at least 42 states cover medical supplies through Medicaid.
When states choose to fund medical supplies, they may place limits on the type and amount of coverage provided. For example, some states have an annual benefit cap for medical supplies and equipment, but others limit the benefit to certain groups. Beneficiaries may be charged a small copayment when they receive supplies through Medicaid. You can find out the rules in your state by contacting your state's Medicaid Agency.
To qualify for ostomy supplies through Medicaid, you'll generally need to prove that you have a medical need for your items. Your doctor can verify that your supplies are medically necessary. Many states also require enrollees to obtain their supplies from an in-network supplier.
Does Medicare Cover Ostomy Supplies?
Medicare usually covers ostomy supplies as prosthetic devices through Part B for enrollees with a colostomy, ileostomy or urinary ostomy. It doesn't place limits on the amount it covers. Instead, Medicare covers the supply quantity states on your doctor's prescription. Medicare covers 80% of the approved amount, and beneficiaries are responsible for paying the remaining 20%. You'll also need to pay the Part B deductible.
Medicare Advantage Plans must provide the same benefits as Original Medicare, but insurers can provide additional benefits. Therefore, your Medicare Advantage Plan will cover ostomy supplies if you meet the eligibility criteria for Original Medicare coverage.
Are Ostomy Supplies Considered a Prescription?
You can purchase your own ostomy supplies out of pocket if you don't have health care coverage. However, you'll need a doctor's prescription if you want Medicaid, Medicare or a private insurer to cover your ostomy supplies.
Why Are Ostomy Supplies so Expensive?
The annual out-of-pocket costs for ostomy supplies can be as high as $3,000 per year with insurance, but Medicare enrollees won't typically pay as much as that. Eligible Medicaid enrollees typically get their ostomy supplies for free or pay a modest copayment. However, costs such as copayments and deductibles can be high if you rely on private insurance, causing many people with ostomies to experience financial distress.
Many countries provide medically necessary ostomy supplies for free through their public health care schemes, but the United States doesn't. People with ostomies need to change their ostomy bag every 3 to 4 days, and they may need to change them daily if they experience complications. Therefore, the need for frequent changes means that supplies cost between $300 and $600 per month.
Where Else Can I Get Help With the Costs of Ostomy Supplies?
If you don't qualify for Medicaid and Medicare or you don't have adequate private health care coverage, you may be eligible for other support. Some manufacturers operate assistance programs to help people with their supply costs, and you can contact manufacturers directly to apply. Some hospitals and other health care settings also keep a bank of donated supplies to support people struggling with the costs of ostomy supplies.
Some distributors also provide low-cost ostomy supplies. The United Ostomy Associations of America keeps a list of low-cost suppliers and organizations offering assistance on its website.