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Medicare Coverage of Ostomy Supplies

Gina Flores
Caregiver Advocate | Shield HealthCare
09/06/11  11:45 PM PST
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 February 2016

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:

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Serving Medicare Ostomates Nationwide
My 89-year-old mother loves to swim but she has found that the pouch fills with water when she gets into the pool. What can we do to fix this?
Cathy
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13 Comments

  1. Cindy Weaver
    Posted September 24, 2013 at 4:01 pm PDT

    I don’t understand how Medicare can tell a person how many ostomy supplies he/she can have each month !! There is NO way of telling how many you will need each month because of leaks. Even if the skin around the stoma is ok, there can always be leaks! I have experienced this many times !

    So what is a person supposed to do if they run out? Paying out of pocket would be VERY expensive!

    Cindy

  2. Posted September 24, 2013 at 9:57 pm PDT

    Hi Cindy,
    We understand your frustration. Unfortunately, the amount of supplies you can order is limited by Medicare. Since Medicare may approve increased supplies if your doctor deems them medically necessary, we recommend you speak with your primary care physician. You might also consult with an ostomy support group for ideas or suggestions.

  3. marliyn balsse
    Posted March 31, 2015 at 11:18 pm PDT

    No, you do not understand our frustration as a colostomy patient. I have used 10 bags within 2 days if I have the flu or a virus or leaks. Medicare is very unfair with colostomy patients. diabetic patients receive free shoes and other free supplies. I do not know who in medicare made the rules for colostomy patients but they are way off base.

  4. Brett
    Posted May 5, 2015 at 2:20 pm PDT

    What about stoma paste?

  5. Aimee Sharp
    Posted May 5, 2015 at 6:44 pm PDT

    Hi Brett. Thank you for your question. It looks like 4 ounces of ostomy paste per month is eligible for reimbursement through Medicare. You can find more information about Medicare reimbursement here, if need be. Thanks for commenting!

  6. Tom
    Posted September 30, 2015 at 12:40 pm PDT

    Will Shield accept a prescription from a doctor calling for what the doctor determines medically necessary even though it is more that medicare normally allows?

  7. Aimee Sharp
    Posted October 1, 2015 at 3:03 pm PDT

    Hi Tom. Thank you for commenting. To answer your question: In general, Shield HealthCare follows Medicare’s guidelines. If you have a specific question, we’d ask that you give us a call and we would be able to discuss. 800.765.8775. Thank you! -Aimee, Shield HealthCare

  8. Mary Jane
    Posted March 8, 2016 at 6:48 am PDT

    do you all accept Medicaid

  9. Aimee Sharp
    Posted March 18, 2016 at 4:58 pm PDT

    Hi Mary Jane. Thank you for your question. We accept Medicaid in IL, WA, CO and TX, and Medi-Cal in California. Please let us know if you have any other questions. Thank you. -Aimee, Shield HealthCare

  10. Nancy
    Posted March 25, 2016 at 4:50 am PDT

    What kind of note do I need from my Dr? Does
    he have to list what supplies I need- like numbers? How do I get the note to you?
    Thanks

  11. Posted April 14, 2016 at 3:43 pm PDT

    Hi Nancy, thank you for your question! In order to receive ostomy products, a prescription from your doctor is required. Depending on your state and your insurance, there may be other variables involved. We would be happy to give you a more detailed answer – at your convenience, please contact us at 800.765.8775 and we will be glad to assist you. -Brooke, Shield HealthCare

  12. Mark
    Posted May 11, 2016 at 11:01 am PDT

    I have a stoma in the neck area. Medicare and Medicaid will only cover orders/ claims for diagnosis and codes for Colostomy, lleostomy, and Urostomy. Is there something I’m missing relating to coverage for unique stoma ostomy pouch supplies? I can’t afford the out of pocket cost. Has anyone had a appeal court hearing with any success?

  13. Aimee Sharp
    Posted August 15, 2016 at 2:33 pm PDT

    Hi Mark. Thanks for commenting. I’m sorry, but we don’t have any information about that type of ostomy pouch and its coverage. Hopefully a fellow reader will see your comment and answer. We wish you the best of luck in the meantime! -Aimee, Shield HealthCare

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