Changes in Insurance Allowables for Rings, Flanges, and Pouches

Replies
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339
blt.tinkerbell
Jun 25, 2024 3:46 pm

Have any of y'all noticed that certain insurance companies allow only 10 rings but 20 flanges and 20 pouches? It used to be 20 of each. Then last month (June) it went down to 10 for the rings. I'm really trying... But the math here just isn't adding up.

AlexT
Jun 25, 2024 4:53 pm

Every insurance carrier has different amounts; it all depends on who you have insurance with and the contract that your employer has with that insurance company.

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Beth22
Jun 25, 2024 5:41 pm

It does depend on the insurance, but you should be getting at least 20 rings for the month, same with barrier strips. Unfortunately, your insurance company isn't going to know anything about what is covered; they have no idea what you're talking about. The best bet is to call your distributor, ask them how much of each is covered, then call the insurance company and ask why, or have your doctor state and fax over a new prescription saying you need 20 rings per month to the insurance company.

Hisbiscus
Jun 25, 2024 6:51 pm

You're going to have to maybe have them do a prior authorization to get the extra ones added to your prescription. The doctor will need to write a new script for the 20 with documentation, which they may already have, and the medical reason, which would be leaks and skin problems without them. Then the DME has to submit a prior authorization to the insurance company, and their prior authorization department will decide to give it to you or not depending on the medical need for it. It takes time for all this, but it's worth getting it started to see if you can get them.

Nellienad
Jun 25, 2024 6:57 pm

Hopefully, someday all insurances will match the CMS Medicare guidelines with an outlier for "extra" with supporting MD documentation, just like what's done for other DME (oxygen, diabetic supplies, etc.). It's such a burden for the ostomate to deal with as medical staff, insurance staff, and contracted DME providers seem clueless in coordinating the essential-to-life needed ostomy supplies. You have to be your own advocate every step of the way.

 
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AlexT
Jun 25, 2024 8:33 pm

If people running the health insurance industry had any sort of health conditions that required continuous equipment, there would be no issue getting proper amounts of supplies.

blt.tinkerbell
Jun 25, 2024 10:04 pm
Reply to Beth22

Yes, I do have an extra allowance from the provider to the insurance company. I work outside five days a week, and it was already in the 100s here in May. Sweating all day takes a toll on the longevity of my appliance. I was just wondering if anyone else has BCBS. It used to cover 20 a month and now only 10 for rings, but still 20 for flanges and pouches. I called the insurance company today and had it escalated. They called EdgePark for me and told them to put it in the system as 20 allowed per month. Hopefully, it works!

warrior
Jun 25, 2024 10:55 pm
Reply to blt.tinkerbell

BCBS did you right. I have them. No issues. Edgepark. No complaints. I hope it works out for you. You've got to be on top of this stuff.

Hisbiscus
Jun 26, 2024 1:37 am
Reply to blt.tinkerbell

I hope you get them. My fingers are crossed for you. It's sad because non-ostomates can go to a toilet and only need the toilet and the toilet paper, which is easy to get. We have to wear these things and stress out about getting what we need. I feel ya!

Beth22
Jun 26, 2024 11:55 am
Reply to blt.tinkerbell

I had BCBS; 20 was always covered. I've never heard of only ten, even when you have Medicaid, 20 is covered. It seems like it's happening from your distributor. I had Edge Park; I know how they are. You can switch to a DIY distributor. You can always call another one, make sure they take your insurance, and ask them how many you would get.

blt.tinkerbell
Jun 27, 2024 2:11 am
Reply to Beth22

It's definitely on BCBS's end. It's on their website of allowables. The top line is what it switched to as of June.

 

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blt.tinkerbell
Jun 27, 2024 2:11 am
Reply to Beth22

 

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It's definitely on BCBS's end. It's on their website of allowables. The top line is what it switched to as of June.

 

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Beth22
Jun 27, 2024 3:51 am
Reply to blt.tinkerbell

That's really weird. I just had BCBS and had to switch insurance a couple of months ago. I always had 20 covered for the month.

trifinisher
Jun 29, 2024 8:50 pm

Hmm... not sure if this is just an American thing. As a Canadian living in BC, my provincial healthcare covers most ostomy supplies after any other insurance doesn't, with no limits on anything, except "reasonable amounts." I change my whole works every three days. My yearly cost is around $200 - $400 total. I have about 2 years of supplies built up.

IGGIE
Jun 30, 2024 11:28 am

I really feel for you guys. It's hard enough just being an ostomate, but having to work with an antiquated system like you seem to have must be debilitating. I keep saying it, guys, but get together and work on the government to adopt the same system that we have in Australia and, I believe, also in the UK. I pay an annual fee of $60 for the year and all my products are free.
Regards, IGGIE

Doe1mama
Jun 30, 2024 1:48 pm

We have BCBS Personal Choice 65, so it's probably different. But it's still 20.

Andrew82
Jun 30, 2024 5:13 pm

Medical Monks is a great alternative if you run into insurance roadblocks.

vanestag
Jun 30, 2024 8:24 pm
Reply to Beth22

Edgepark likes to set their own rules and regulations! Fortunately, when I was on private insurance, I stockpiled supplies. Now on Medicare, they seem to tell me the limits on supplies, and it changes on just about every other order. Supplies are always on backorder. Hopefully, I'll change suppliers if I can find one that carries Sensura Mio.

Beth22
Jul 01, 2024 12:31 am
Reply to vanestag

I couldn't handle having Edgepark. I left and switched distributors because of all the crap they pulled with me. The best way to find out who takes your insurance is to call the distributors and ask if they take your insurance. None of us deserves to be left without supplies or be given the runaround or lied to.

I use sensors Mio as well. I know Byram carries it; Comfort Medical carries it as well.