|Its strange reading through some peoples posts, that some of you have to pay for your Ostomy supplies. Here in the UK , I just go to the Docs.Sign my ready printed presciption & they send it direct to Charter Healthcare ( My Suppliers) 2-3 days later my supplies arrive , Delivered by Parcel Force. I usually order every 4-5 weeks . I get 30 Welland Uro pouches.. 30 Ptotective Wipes . 10 Colorplast Night bags, This company also throws in , Gratis, 2 packs disposal bags, 2 packs Dry wipes & 1 large general wet wipes. I often complain about the British National Health Service... but my surgeon was brilliant... I get free supplies & I dont pay a penny!!!|
I live here in san antonio, texas, and the insurance companys consider urostomy supplys a )band aid) An will not pay for any of it
First, anyone can buy ostomy supplies without a prescription. To get insurance to PAY for it though, you must have an MD prescription. An experienced or good ostomy supply company will often help you through the process, whether Medicare or managed care which needs authorization.
Most inurance companies follow Medicare guidelines in tems of what items are covered and how much insurance will pay. Confusing, but in general Medicare will pay for 80% of what Medicare deems allowable as the cost and for "allowable" (standard used) items. The 20% balance is up to you; if you have a secondary insurance they will usually pick up the balance. Example: If your pouches cost $100 and Medicare allows/covers $100 for that particular supply, they will pay $80 of it (80%). Balance is yours to pay if no seondary insurance. If they only allow $50 coverage for that particular product, then they will only pay 80% of the 50 bucks, even if the item you want costs $100. Meaning, they would pay $40 on that item, and you would pay $60 out of your pocket if no secondary insurance. It gets messy. Suggestion: if Medicare, look for an ostomy supply company that "accepts assignment" from Medicare. This means they bill Medicare directly, and accept whatever payment (measly?) Medicare will give them, you don't have to put money out of pocket or wait to get reimbursed. It can get sticky, as some ostomy items are not ocovered or they will not accept assignment on certain things/brands.
Private insurances: (Managed care HMO and PPOs) all plans vary; some won't pay for ostomy supplies period though that is rare. some have a co-pay, either percent of cost or flat fee. The KEY: get authorization, go to he company they CONTRACT with. It is a PITA....but not impossible. Many HMOs first line is to deny, deny. Be persistant, check your insurance booklet. It should becovered under "prosthetics" If still refused, write a letter of appeal. I have done this for patients who needed more supplies than the usual allowance for imperfect stomas or personal reasons and insurance saw the logic. with the physician countersigning. Sometimes they are even more generous than Medicare (if they don't know better!) Call your insurance provider and ask who they contract with and to provide authorization. They may ask you for a list of supplies, or have you go to your primary MD or surgeon and they will put it through the process for you.
Be aware...a lot of folks think they have Medicare when in fact they have signed that over to a managed care Senior Health plan. That is OK...but if you have done that, you need to go with the ostomy supply company that plan contracted with or you will be responsible for the charges. If a home care nurse is seeing you and you are under Medicare, that home care is being PAID by MEDICARE to provide you with ostomy products as long as the home care nurse is seeing you....if you order supplies while under home care, Medicfare will NOT pay for them until you have been discharged by that home care agency.
Medicaid/Medical (called different names in different states): My experience is lately they are trying to dictate what brand you wear to keep their costs down. So, they may not cover certain Convatec items, but would cover the same thing in another line such as Hollister or Coloplast. All good companies, check with your ostomy nurse though on what is the equivalent......I have issues with a person on the phone who has never seen a stoma much less the patient looking at a catalogue making clinical judgements on ostomy wear, telling them it is "equivalent"...they don't know the whole picture. Check with your ostomy nurse first if they won't give you what you are asking for.
My last suggestions: If you have NO insurance or your ostomy items really aren' covered, there are a lot of companies that will actually give a CASH discount...but you have to ask. Be active in your local or national ostomy associations: politicians have been trying to get ostomy item coverage taken out of both Medicare and Medical/Medicaid in the past....it was the ostomates who prevented that from happening. Supplies sure are not cheap out of pocket!
* Certified Wound and Ostomy Care Nurse
* Registered Nurse
* Bachelor of Science in Nursing