General Medicare Guidelines for Ostomy Care
In this article:
- Hospital and doctors’ fees
- Ostomy supply coverage
- Number of supplies covered [download PDF (102 KB)]
As you may know, Medicare is a federal insurance program. It covers people over age 65 and younger people (under age 65) who have certain disabilities. If you have Medicare insurance, here is some general information about ostomy-related coverage. You will always have a need for regular doctors’ visits for ostomy supplies, and it’s helpful to know what is covered by your Medicare insurance.
Hospital and doctors’ fees
Everyone* over age 65 is entitled to Medicare Part A coverage. Part A is hospital insurance coverage. It covers hospital inpatient care and care in skilled nursing homes (but not long-term care). It also covers some home health care and hospice care. You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes for at least 10 years while working. Doctors’ fees and outpatient care would fall under Medicare Part B, which is optional coverage. People who choose to receive Medicare Part B pay a monthly amount, or monthly premium, to get this insurance coverage. Part B helps cover eligible doctors’ visits, lab tests and outpatient care. It also helps pay for supplies, including ostomy supplies, when they are medically necessary. After you pay the Part B deductible for the year, Medicare pays for 80% of the Medicare approved charges for your doctors’ visits and supplies. You pay the other 20%. (Individuals may separately buy a supplemental insurance policy to help pay for this 20% of costs.)
* Those covered under Medicare are all U.S. citizens and lawfully admitted noncitizens who have lived here for at least five years.
Ostomy supply coverage
If you have Medicare Part B coverage, then your ostomy supplies are covered. (As noted above, Medicare pays 80% and you pay 20%.) You must have a prescription, signed and dated by your doctor, on file with your supplier. It is important to make sure that your supplier is enrolled in Medicare and has a Medicare supplier number. Otherwise your claim will not be paid by Medicare.
Before you order your ostomy supplies, ask the supplier if it is a participating supplier in the Medicare program. Participating suppliers must accept assignment. “Accept assignment” is a term that means the supplier agrees to accept the Medicare-approved amount. If your supplier accepts assignment, it can save you money. If your supplier does not accept assignment, you may have to pay for the entire bill, and then seek reimbursement from Medicare on your own.
