As a Medicare beneficiary, you may have questions about insurance coverage of your intermittent catheters. Intermittent catheters are covered by Medicare once certain criteria are met. In today’s article, we will discuss exactly what is needed to obtain Medicare coverage of your catheters.
Step 1: See Your Healthcare Provider
The first step in obtaining Medicare coverage for your catheters will be to visit your Healthcare provider. Your Healthcare provider must write a prescription (also known as a standard written order) for the catheters. Without a Healthcare provider’s order, the catheters will not be covered. In addition to the order, your Healthcare provider must also provide note in your medical record explaining why you need catheters. This is often referred to as a “Healthcare provider progress or visit note”. This note must contain the following information:
- A medical diagnosis of the condition that results in the need for catheters. A diagnosis of urinary retention, incomplete bladder emptying, or urinary incontinence can be used to justify catheter coverage.
- A statement confirming that this diagnosis is chronic or permanent. In this case, “permanent” means that you are expected to need the catheters for at least 3 months.
- Frequency of use. This is the number of catheters your Healthcare provider expects you to use. This is typically written as the number of catheterizations recommended per day.
How Many Intermittent Catheters Can I Get?
Medicare will cover up to 200 sterile intermittent catheters per month. However, it is important to understand that Medicare will only cover what has been ordered and recommended by your Healthcare provider. The number of catheters on the order and the frequency of catheterization recommended in the Healthcare provider’s note must match. For example, if your Healthcare provider has recommended that you use a catheter five times per day in their note, the number of catheters on the order must equal to 5 catheters per day, or 150 per month. If the current number of prescribed catheters does not meet your needs, you will need to contact your healthcare provider and discuss increasing the order. Then your Healthcare provider must provide both a new order and new note (visit is required) with the increased frequency of use.
How Much Will Medicare Pay?
As long as you have Medicare Part B coverage, once catheters have been determined to be medically necessary, Medicare will pay 80% of the cost based on their published fee schedule after the annual deductible is met. A deductible is the amount you must pay out-of-pocket before your insurance plan begins to pay. The fee schedule remains the same regardless of provider as long as the provider accepts Medicare’s reimbursement rate in full, and we do. This is commonly referred to as participating. Deductible amounts vary calendar year to calendar year for Medicare and Medicare managed plans, check with your insurance plan to determine your annual deductible as this can vary from year to year.
The Importance of Medical Supply Companies
The process of obtaining insurance coverage for your medical supplies can be confusing. Mistakes can be costly. A high-quality medical supply company serves as a navigator between you, your insurance, and your Healthcare provider to ensure that all of requirements have been met for coverage and you are getting the products you need.
At ABC Medical, we will reach out directly to your Healthcare provider’s office to obtain the necessary documentation. We will also submit the documentation to your insurance provider on your behalf. We pride ourselves on adequately helping you navigate your insurance.
Please call today if you have any questions about product coverage or would like guidance on obtaining insurance coverage of your medical supplies.
Please Note: Additional medical necessity and coverage criteria exists for products such as curved or coude tip or for a closed system catheter. For more information on closed system catheters and their medicare coverage requirements, click here.
Disclaimer: This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. For medical advice, please speak with your healthcare provider.
References: 1. Urological Supplies. Centers for Medicare and Medicaid Services. Updated April 1, 2021. Accessed June 29, 2022. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33803