Affording Ileostomy Supplies Without Insurance Coverage

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713
Barbie400
Jan 26, 2025 12:20 am

Hi everyone

I had my surgery 3 months ago- permanent ileostomy. At the time I received a three month supply through edgepark, my insurance covered the supplies. 
I have private insurance- BCBS of MN. 
Edgepark called me now to make a new order, but seeing that we are in January and I haven’t reached my out of pocket maximum yet, I called my insurance to make sure that they will be paying for the supplies again. They said they won’t until I reach my out of pocket maximum. 

I feel like I’m missing some vital information here, how does everyone afford supplies if insurance doesn’t cover it?!?!?

Any help would be appreciated!

Thank you 

Gracie Bella
Jan 26, 2025 12:31 am

I never realized how blessed I truly am that I live in New Zealand.
I don't have to pay for any of my ileostomy and medical equipment, as the hospital pays for it; we now automatically receive a month's worth of supplies every month.

Since joining earlier this month, I have wondered how people who can't afford their supplies manage.

I can fully understand how frustrating this must be for you, and other people who do not have the support of "Health New Zealand", and have to pay for their own supplies. I have looked on the internet to see how much my supplies would cost if I were not this fortunate, and was completely shocked by how expensive all my supplies are!!

I pray someone can help you!!

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aTraveler
Jan 26, 2025 1:18 am

Ostomy Supplies are considered durable medical equipment (DME). Under my insurance coverage, DME is not subject to the annual deductible but I have to pay 20% co-insurance per item.

You may want to check your policy to see your responsibility for DME. Max out of pocket typically means you no longer have to pay any medical costs once it is met 

Your supplies won't be FREE until you reach your max-out-of-pocket costs but you probably only have to pay a percentage of the cost contingent upon whether you have to meet your  annual deductible.

SusanT
Jan 26, 2025 1:32 am

I have a flexible spending account to cover my out-of-pocket expenses until my annual out-of-pocket max is met. The one I have lets me spend money that I plan to save so it's available now.

I had cancer, and my ongoing medical issues and surveillance mean I will reach that max this year.

There are supply closets for ostomy supplies that might be able to help you keep costs down. Check UOAA; there's also a couple of people on this site, but I don't remember who. Check old threads.

warrior
Jan 26, 2025 1:35 am

Insurance does cover it, most of the bill, yes...

But there's always a deductible amount—a limit set—you yourself have to pay. Are you not familiar with this process?

Dental services too have this. You reach your deductible, then the insurance company pays a portion, then you pay the copay.

Until you reach your OOP (out of pocket), you pay.

You sound surprised at this process. It happens to everyone with insurance.

Now, if you are ever stuck without equipment, Kas and I have extra supplies. Kas is from MN. Contact her if you can.

Many people have reversals seeking to donate their unused equipment. We take it and offer it to those stuck.

No questions asked.

FYI—I have BC/BS of NJ and I use Edge Park for years.

If Kas and I can help, send out the item numbers of everything you need/use. Let's get that sorted first, okay?

 

 

 

 

Staying Hydrated with an Ostomy with LeeAnne Hayden | Hollister

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Beachboy
Jan 26, 2025 2:15 am

I had BC BS of California for a year and a half after I got a colostomy.  My supplier was Edgepark.  After I met the $2,000 deductible, my Ostomy supplies cost $247 every 3 months.  If "Max out of pocket" is reached, then everything is free for the rest of the policy year.  

Your policy is probably different than mine.  But you should have a yearly deductible.  And a Max out of pocket amount. 

If your deductible is not met, you pay 100% of the cost of medical services, until it is met.  Your cost should be lower though, because medical insurance companies have contracted rates with hospitals and medical suppliers.  

Call your medical insurance help desk to find out what your coverage is for ostomy supplies, and contracted prices for Edgepark supplies.

I found even though my deductible was not met, the amount I paid for Edgepark supplies was lower than if I bought them on my own.

I now have Medicare Part A and B.  With a medigap G supplemental plan.  I still use Edgepark, but receive less supplies.  And still pay about $200+ every 3 months.

Maried
Jan 26, 2025 3:12 am

A couple of jobs ago, I had to buy $1500 worth of ostomy supplies, then a 20% discount. If I did not have the cash, I used my credit card to pay for the supplies. My current job has Kaiser, an HMO, and the supplies are 100% covered. Ostomy supplies are very expensive.

bobwilson5999
Jan 26, 2025 1:36 pm

Insurance companies, for retirees, operate in much the same way across the board. 1.) You have to exceed an annual "deductible" before they will pay. 2.) They may only pay part of your claim, for example, 80%. 3.) They also may have an annual ceiling after which you must assume the cost on your own. Fortunately, here in Ontario, we have an Adaptive Devices Program (ADP) which provides about $1000 in assistance. As well, there is a federal income tax deduction one can apply for that amounts to about $10K (in deductions only, so you only realize a percentage of that amount). And finally, one can claim all the stuff you had to pay out of pocket as a medical expense (again a percentage deduction). All in all, better than a poke in the eye with a sharp stick.

IGGIE
Jan 26, 2025 2:28 pm

You guys have to approach your political parties and pester the hell out of them to do what Australia, New Zealand, England, and Canada have done. All our products are free, totally free.

Someone start the ball rolling and contact even Trump as he is doing a lot of changes right now; see if he can fix this for you.

Regards, IGGIE

Barbie400
Jan 26, 2025 3:31 pm

I was aware that my insurance only starts paying a % after I reach my deductible and then 100% once I reach out of pocket maximum, but for some reason I was under the impression that Ostomy supplies are always covered. I am not sure where I picked this up or if this was just my assumption. 

My insurance did tell me that for some diagnosis like epilepsy they do cover the meds 100% before any deductible has been reached. The agent mentioned a few other conditions too, but I can’t remember what they were. I’m wondering why the same doesn’t apply for Ostomy supplies?

I also tried to google this and saw there is some grant for Ostomy supplies, has anybody looked into this? 

aTraveler
Jan 26, 2025 3:32 pm
Reply to IGGIE

IGGIE, as a patient, I can say "Free  Healthcare is a non-starter in the United States."

There’s an aphorism taught to medical students that goes like this: “Listen to the patient. He is telling you the diagnosis.” 😉

Maried
Jan 26, 2025 4:07 pm
Reply to IGGIE

I know you are joking 🙃 

Hugo
Jan 26, 2025 4:39 pm

I have Kaiser, which covers 100% of my supplies. However, I only get 20 colostomy pouches a month, which is not enough.  I buy more through Amazon for about $40 for a box of ten. Ostomy supplies are absurdly expensive.  We need a complete overhaul of our health care system.  We are the richest nation on earth and leave our less fortunate hanging out to dry.  It’s disgusting how greedy our nation has become.

IGGIE
Jan 26, 2025 4:40 pm
Reply to Maried

Why do you think I am joking?

k9rulz
Jan 26, 2025 4:59 pm

I have Carefirst Bluechoice in VA (basically Blue Cross for VA). There's an annual deductible and an out of pocket maximum. You pay the "negotiated" rate/price of services/items until your deductible is met. If your total out of pocket (deductibles/copays/etc) exceeds the out of pocket maximum for the CALENDAR year (Jan-Dec) you pay nothing after that amount is hit. Everything resets to 0$ on Jan 1 of the next year.

How your deductibles, co-pays, co-insurance and out of pocket expenses are calculated is kinda tricky based on your contract, the best thing is to call your insurance and walk through it with them.

My ileostomy supplies, as aTraveler said, are considered DME, so usually you pay the negotiated price for the supplies until you hit your deductible, and then the co-insurance (usually like 20%) after that. I'm currently trying to walk through all my hospital expenses from my emergency surgery/hospital stay that spanned from Nov-Jan - so I get to pay figure out what was LAST year's medical expenses and what was THIS years because everything resets on Jan 1. Fun Times!

Good luck. Your best bet is to call them and explain in more detail what you need. You may have had a less competent agent on the phone who wasn't able/capable of understanding your situation and getting someone else can help. Don't just believe the one agent who seemed to tell you something that seemed "wrong" to you. If that happens, hang up and call back and talk to another agent, or ask to speak to a manager to better explain things.

aTraveler
Jan 26, 2025 5:03 pm
Reply to Hugo

Are these closed-end pouches — Medicare allows for 60 pouches a month.

SusanT
Jan 26, 2025 6:48 pm
Reply to IGGIE

Your healthcare system is massively controversial here. 

And the kind of change you propose is exactly the opposite of what Trump stands for. 

PS I do agree we need reform here. Not arguing just explaining why what you said sounds funny. 

AlexT
Jan 26, 2025 6:51 pm
Reply to IGGIE

There's too much money involved in changing it. And guess who would stand to lose fortunes if it were changed. 🤔

Karliegirl33
Jan 26, 2025 11:14 pm

Same here. New year, new deductible to meet. I use Edgepark and was placing an order last week online and when the copay amount came up I was shocked.

Check ebay.  I order supplies from a few different vendors on there. Very reasonable and never had any issues. Just make sure expiration date is good.

 

 

warrior
Jan 27, 2025 1:14 am
Reply to Karliegirl33

Hey girl... are you saying you actually saw a copay amount listed when ordering from Edgepark?

I don't get my copay amount until after the products arrive.

Who do you know at Edgepark? 😆

Kas
Jan 27, 2025 1:18 am
Reply to Barbie400

Hey Barbie. I also have BCBS of MN and haven't had a problem, but I also meet my max out of pocket in the second week of January.

I will be at Mayo on February 14th and see you're in Rochester. If you send a list of needs before that, I'll bring it with me if you can meet me somewhere. I'll also send you a PM.

 

Maried
Jan 27, 2025 1:36 am
Reply to IGGIE

I'm sorry... that sounded harsh.

Republicans are known for not giving away anything, especially to the needy. Trump just wrote an executive order to stop the bill Biden put in place to reduce the cost of drugs for people using Medicare and medical programs that help seniors and the very needy. While an executive order is pretty much a wish list, it is clear he does not approve of a reduction in drug prices. Ostomy supplies being free would be so wonderful, but I am pretty sure there would be no success; this government loves enriching the medical manufacturers.

Hugo
Jan 27, 2025 1:44 am
Reply to aTraveler

No, I use drainable pouches.

aTraveler
Jan 27, 2025 2:17 am
Reply to warrior

I always pay my copay when I order from EdgePark. Since I always order the same thing, my copay is no mystery. 😉

warrior
Jan 27, 2025 2:24 am
Reply to aTraveler

Maybe because I have commercial insurance, I do not see any copay. In fact, after ordering online, it just shows zero copay. Then a week later, I get a bill for stuff I ordered.

Never more than 30 bucks. They have that auto-order thing. No issues, no complaints, just curious about co-paying up front. I see no prices whatsoever on the invoice. I honestly don't know the cost until a week later, or after the item arrives. Hmm. 🤔

SusanT
Jan 27, 2025 2:27 am
Reply to warrior

Edgepark tells me when I check out. 

I don't think it's a matter of knowing someone at Edgepark. 

Who did YOU piss off at Edgepark? 🤣

warrior
Jan 27, 2025 2:31 am
Reply to SusanT

Everyone it seems... nah...

They love me there. No sooner do I get supplies than they're telling me an order is pending... what? Yes, money talks. They want it.

Missb
Jan 27, 2025 2:32 am

I deal with Edgepark also. I have a $257 deductible every year from Medicare, so Edgepark would not send my supplies unless I paid them the amount of the whole bill, which was shy of the $257, so I added something else so it came to the exact amount. Now all my stuff and doctor visits will be paid for. I have a second insurance that picks up the rest. As I said, I had to pay that, or I would not get any supplies.

warrior
Jan 27, 2025 2:35 am

I dread Medicare. They have limits to supplies, right?

No thanks. I will work. I will get my maximum amount of supplies per month and stock up for a rainy day.

aTraveler
Jan 27, 2025 2:44 am
Reply to Hugo

You should be able to use a drainable pouch multiple days. What is preventing you from using a drainable pouch multiple days 🤔