Medicare Coverage of Ostomy Supplies

One of the most common questions about home medical supplies is “what’s covered?” Specifically, Medicare coverage of ostomy supplies. Because managing an ostomy at home involves ordering an assortment of products and accessories, knowing what to expect is helpful.

Qualifying For Ostomy Supplies

Original Medicare has two parts. Part A: Hospital Insurance that covers hospital, home health and skilled nursing stays and Part B: Medical Insurance that covers a variety of outpatient services including medical supplies, including ostomy supplies

Medicare eligibility and payment guidelines for Part B benefit:

• Monthly Premium – automatically deducted from Social Security check and amount changes every January 1st
• Annual Deductible – Medicare beneficiary is responsible for an annual deductible for Part B supplies or services beginning every January 1st
• Allowable Fee – Value determined by Medicare for the supply or service
• Medicare responsibility – 80% of allowable fee
• Beneficiary responsibility – 20% of allowable fee

To qualify for ostomy supplies for care at home, you must have Medicare Part B coverage and your doctor’s documentation of your need for the supplies in your medical records. The doctor must also write you a prescription or order for the supplies clearly stating which supplies you will need. Your doctor will know what’s necessary to qualify for the type of supplies prescribed for you. You are allowed up to a three-month supply of ostomy products at one time. Ostomy supplies are covered for people with a colostomy, ileostomy or urostomy.

How Much Ostomy Supplies Will Medicare Cover?

Medicare decides the amount of supplies you may order each time. The quantity of supplies needed by each person is decided by the type of ostomy, its location, its construction and the condition of the skin around the ostomy. Medicare may approve increased supplies if those supplies are deemed medically necessary by your doctor.

If you receive your Medicare through a Medicare Advantage Plan (such as an HMO or PPO), there may be additional benefits and other criteria for ordering your supplies. Make a point of checking with your health plan’s customer service department before ordering your supplies.

Typical Ostomy Product Quantity Guidelines

*Updated September 2018

Convex Inserts                          10 per month

Closed 1 piece Pouches          60 per month

Closed 2 piece Pouches          60 per month

Drainable 1 piece Pouches    20 per month

Drainable 2 piece Pouches    20 per month

Irrigation Bags & Tubing       2 every 6 months

Irrigation Cones                       2 every 6 months

Irrigation Sleeves                    4 per month

Non-sterile Gauze Pads          60 per month

Ostomy Belt                                1 per month

Ostomy Wafers/Barriers       20 per month

Pouch Deodorant                     4 oz. per month

Skin Barrier Liquid or Spray  2 oz. per month

Skin Barrier Wipes or Swabs  150 every 6 months

Stoma Caps                                  31 per month

Visit Shield HealthCare’s online reimbursement guide for more Medicare ostomy product coverage details.

For more information on Medicare coverage, visit mymedicare.gov for personalized information based on your individual benefits and available services.

For more information, see related ostomy product articles and ostomy resources here:

• Ostomy Products | Options
• Exercising with an Ostomy | Products That Can Help
  
• Ostomy Terms Explained | Ostomy Glossary
• Ostomy Skin Issues: Your Solutions

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