What catheters Are Covered by Medicare?

Insurance Covered Catheters

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Purchasing a disposable urinary incontinence product is a costly affair. Patients and their caregivers end up spending hundreds and thousands of dollars, per annum, on buying catheters alone. Many of them are unaware of insurance offers that enable them to reimburse and obtain waivers on account of all purchase costs.

There are some instances in which continence products (such as urinary catheters) can easily be reimbursed through different private or public insurance programs. Medicare and Medicaid are two programs that offer such benefits.

Medicare

Medicare is a health insurance program, launched by the US Government. It is applicable for people aged 65 years or older. Individuals below the age of 65 can also avail Medicare benefits if they’re suffering from certain disabilities (such as end-stage renal diseases).

Medicare catheters refer to the intermittent catheters that are typically covered under the health benefit plan. It allows full reimbursement against a maximum of 200 sterile and single-use catheters per month when procured from licensed and registered catheter supplies.

This benefit is subject to certain checks, balances, and verifications. The patient will require a doctor’s prescription and must be suffering from a permanent urinary incontinence or retention issue. Furthermore, the patient or caregiver must be able to perform self-catheterization.

Medicare covers closed system catheters. Additionally, the individual should suffer from permanent urinary incontinence and needs to provide documents so as to apply for full reimbursement, in respect of the cost of catheters.

The Medicare member must have two distinct UTI’s while on a program of sterile intermittent catheterization. These must occur between 12 months of one another. Secondly, the member must reside in a nursing facility.

If insured with Medicare, then you probably know that Medicare guidelines can be unclear and confusing in most cases. This is particularly the case when it comes to medical equipment and supplies that are used in homes, as Medicare does not pay for most, if not all, such equipment and supplies. So here, we will give you a simple breakdown of the urological devices and supplies that are covered by Medicare.

What Is Not Covered

Let’s start with the equipment and supplies that are not covered by Medicare:

  • Any equipment that is not suitable for use at home, including different types of DMEs used in nursing facilities and hospitals like oscillating beds and paraffin bath units.
  • Any equipment that is primarily intended to provide relief, assistance, and/or support outside your home. For example, if you can walk short distances on your own and can get around your home, then Medicare will not pay for motorized scooters.
  • Most supplies purchased for comfort or convenience with little application as to your conditions.
  • Supplies that are disposed after use or are not used in equipment are also uncovered. This includes incontinence pads, surgical facemasks, compression leggings, and some catheters.

As we just mentioned, some catheters are not covered by Medicare as they fall under the disposable supplies category. That being said, if you are under Medicare home health care, then disposable supplies like gauze, intravenous supplies, and also catheters, will be covered by Medicare.

What Is Covered

While Medicare covers different types of catheters, that does not mean that you can buy a bulk of catheters and expect Medicare to cover you for them. First of all, to qualify for coverage, an individual must be diagnosed with long term or permanent urinary retention or urinary incontinence.

If that is the case, then you should know that intermittent catheters and foley catheters are considered as Prosthetic Benefit under Medicare. In other words, these two catheters replace an internal body organ, entirely or partially, or a part of function of a malfunctioning or inoperative internal organ.

Keeping that in perspective, there are four types of catheters are covered by Medicare in varying quantities without preliminary medical documentation. This includes:

  • Coude (Curved) Catheters – 200 per month
  • Straight Tip Catheters – 200 per month
  • Condom Catheters – 35 per month
  • Foley Catheters – 1 per month

As for external, intermittent, and/or indwelling catheters, an individual will be required to present all the medical information necessary from the physician to get them covered by Medicare. The documentation has to be submitted before the purchase of the catheters so as to allow the person in charge to verify the authenticity.

Another thing worth mentioning is that insertion trays and drainage bags are also covered under Medicare. Typically, one insertion tray is covered per insertion of indwelling catheter, whereas two drainage bags a month are covered for catheter users.

Medicaid

Unlike Medicare catheters, Medicaid assistance is offered by the state government. Accordingly, the eligibility criteria and reimbursement amounts are likely to vary from state to state. In some states, Medicaid insurance grants the patient complete coverage against all absorbent products (including catheters).

In other states, such as Texas, Medicaid has a list of “preferred vendors”. You must place an order with only these vendors so as to obtain reimbursements against all costs of purchases. The program fully reimburses a person for 120 intermittent catheters purchased per month.

Medicaid covers all straight catheters, coude catheters, and catheter kits. It also includes most of the hydrophilic-coated catheter brands and antibacterial product vendors. The insurance program has a strict authorization procedure that must be followed.

Other Programs

Apart from Medicare and Medicaid, there are several other private and public health insurance plans that offer reimburse the cost of catheters. These include, but are not limited to:

  • US Veterans Administration
  • Health Savings Account (HSA)
  • Flexible Spending Account (FSA)
  • Affordable Care Act
  • Diaper Banks Plan

Each of these programs has different rules for eligibility and reimbursement application. It is always best to consult your insurance company and catheter supplies on the coverage offered and reimbursement limits, before placing an order for urinary catheters.