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Ostomy surgery is a complex medical procedure that allows bodily waste to exit through a surgical opening in the abdomen called a stoma into a prosthetic pouch.
Patients may need ostomy surgery due to a wide variety of conditions, including inflammatory bowel disease, cancer, birth defects, severe abdominal or pelvic trauma, and incontinence. This type of surgery can happen at any age and does not reduce life expectancy.
The number of people with an ostomy is on the rise around the world, with roughly a million patients in the US alone having urinary or fecal diversions. Common supplies necessary in such conditions include pouching systems, wafers, adhesive removers, adult wipes, stoma pastes, skin barriers, and gauze, among others.
In this article, we explore Medicare coverage of ostomy supplies, including allowed quantities and relevant time frames.
Does Medicare Cover Ostomy Supplies
Medicare covers ostomy supplies if you have a valid prescription signed and dated by your doctor. Before you can avail of coverage, check for ostomy suppliers that accept Medicare. Remember, Medicare will not pay for your ostomy supplies if your supplier is not Medicare-enrolled.
You can purchase ostomy supplies from large mail-order distributors and local durable medical equipment (DME) suppliers, but they are usually unavailable at local drugstores or retail pharmacies.
For Part B beneficiaries, Medicare covers 80% of the cost of ostomy supplies while you have to pay the remaining 20% out-of-pocket. You can reduce your out-of-pocket liability if you have a Medicare Supplement (Medigap) or Medicaid plan.
If you have a Medicare Part C (Medicare Advantage) plan, it must provide at least the same basic coverage as Original Medicare. That means it must cover ostomy supplies as well. There might, however, be additional eligibility criteria for ostomy supplies coverage under Part C. Contact your insurer to understand these details before ordering.
For Medicare to cover ostomy supplies, you must adhere to allowed supply limits for 30 or 90-day periods.
How Many Ostomy Supplies Does Medicare Cover Per Month?
Your ostomy surgery type determines the quantity and type of supplies you need.
The US Centers for Medicare & Medicaid Services (CMS) sets standard quantities of ostomy supplies that beneficiaries can receive within specific timeframes.
Medicare may cover more items if your doctor specifies the need for extra supplies in your medical record. Without proper documentation, however, Medicare will deny coverage for excess quantities.
The following chart shows common ostomy supplies and their Medicare-allowed quantities per month:
| Medicare-Covered Ostomy Supplies | Allowable Quantity Per Month |
| Drainable ostomy pouches | Up to 20 |
| Urostomy pouches | Up to 20 |
| Closed ostomy pouches | Up to 60 |
| Skin barrier with flange | Up to 20 |
| Adhesive remover wipes | 150 every 3 months |
| Ostomy belt | 1 |
| Skin barrier paste | 4 oz. tube |
| Protective barrier wipes | 150 every 6 months |
| Protective powder | 10 oz. every 6 months |
(Source: 180 Medical, a Medicare-accredited provider)
Note that this list is not exhaustive. It includes some, but not all ostomy supplies that Medicare covers.
Contact CoverRight for further guidance on Medicare coverage of ostomy supplies. Our experienced advisors are here to help you make informed decisions about your healthcare needs.
FAQs
Does ostomy coverage differ if I have Medicare Advantage or Medicare Supplement?
Yes, ostomy coverage can differ if you have Medicare Advantage (Part C) or Medicare Supplement (Medigap) plans.
Medicare Advantage plans must offer the same basic coverage as Original Medicare, but they may have additional benefits or specific criteria for ostomy supplies. Check with plan details carefully for more information.
Medicare Supplement or Medigap plans help cover out-of-pocket costs like copayments, coinsurance, and deductibles that Original Medicare doesn’t cover. If you have a Medigap plan, it can help reduce your cost of ostomy supplies covered under Medicare Part B.
What if I need more ostomy supplies than Medicare’s limit?
If you need more ostomy supplies than the Medicare monthly limit, your doctor must document a medical justification in your records. Your supplier will need this documentation when billing Medicare.
