Medicare spending in the US totaled $917 billion in 2020. This figure is projected to reach $1.78 trillion by 2031 as the population continues to age.
However, with its ever-changing guidelines around coverage and reimbursement, a lot of patients are unaware of the specifics of what their Medicare plan covers. This is particularly true for urological supplies like intermittent catheters.
A patient switching from a Blue Shield plan to a Medicare plan may suddenly find themselves no longer qualifying for the catheter they were using earlier.
That’s why it’s crucial for you to understand Medicare’s guidelines so that you’re better prepared and can minimize any out-of-pocket costs. This article will give you a rundown of Medicare’s guidelines around catheters and answer all your questions about getting coverage of the supplies you need.
Let’s get started.
Does Medicare cover catheters?
The short answer? Yes.
But this is subject to certain conditions. The amount of coverage will depend on the type of catheter a patient uses.
As such, Medicare Part B covers both straight catheters and closed system catheters. Closed system catheters (the ones with collection bags attached) are considered to be more sanitary, more hygienic, and introduce fewer bacteria into the urethra when catheterizing.
Medicare dictates specific guidelines and conditions for both of these.
What conditions does Medicare dictate?
Medicare’s guidelines around the straight catheter are pretty straightforward. A patient needs to have the qualifying diagnosis (e.g., neurogenic bladder dysfunction from a spinal cord injury or multiple sclerosis, etc.). Plus, it needs to be ordered by their doctor, so there has to be an order on file.
The guidelines around closed system catheters, however, are much more stringent. Medicare dictates that patients looking for coverage of their closed system catheters should have had two UTIs (Urinary Tract Infections) within a 12-month period. Also, these instances should have been documented.
For example, if you’ve had only one, which you managed independently with home remedies or over-the-counter medications, Medicare won't consider it to be a qualifier. You’d have to have gone to the doctor and gotten it documented.
What are the limits of Medicare coverage for catheters?
Medicare covers only up to 200 single-use, intermittent catheters (plus one packet of lubricant, if needed) per month. This allows patients to catheterize six times a day (with a few leftovers meant for emergencies).
If you need more than that, you’ll need to support it with additional documentation as to why your doctor has prescribed it. For example, if your doctor puts you on a liquid diet, or if they recommend that you catheterize eight times a day instead of six, they’ll have to notate why they're specifically requesting that for you.
That said, if you’re a Medicare recipient, you’re better off sticking to just the 200 per month.
What steps should I take to get Medicare coverage?
First, set up an appointment with your doctor. It can be with your primary care physician or even a urologist. You’ll need a valid prescription from your doctor for catheters.
Medicare also requires documentation in the form of your doctor’s notes. This should include information on your specific condition, the type of catheter you use, how many times a day you’re supposed to catheterize, etc.
Also, make sure that you get any UTIs documented (if you want the closed system catheter).
Will I need to file claims on my own?
Absolutely not. That’s what we’re here for at Urology Pros. Just call us and we'll take care of the rest.
It's our job to determine your coverage and collect the documentation. We'll get in touch with your doctor’s office directly to get the required information, make sure everything is cohesive, and submit your claim.
Once they’ve reviewed it, they'll let us know the decision. Depending on whether the claim is approved or rejected, we’ll advise you or collect more appropriate documentation. Medicare conducts post-payment audit reviews, which means that it happens after you’ve gotten your devices.
As long as you have the qualifying diagnosis, the written order, and the documentation on file, you should be good. To that end, we may occasionally call you and ask you to see your doctor, if you haven't seen them in a while. Essentially, it's our job to be up-to-date with Medicare guidelines and make sure we're in compliance.
What are my out-of-pocket costs under Medicare?
Medicare covers only 80% of the approved cost of your supplies, so any person under Medicare will always have a 20% copay.
If you have a secondary insurance plan (e.g., Medi-Cal or AARP) like many people under Medicare, then your supplemental insurance can pick up the remaining 20%.
However, in case you don't have a secondary, you’ll need to pay that 20% out of pocket.
What options do I have if Medicare denies my claim?
If your claim is denied, you’ll need to pay for your supplies out-of-pocket. Or if you have a secondary, you can ask them to cover the costs.
In case Medicare decides not to cover closed system catheters, you will need to downgrade to straight catheters until you meet the criteria to qualify for closed system catheters.
Why choose Urology Pros
We get that the process of filing a claim under Medicare can be overwhelming. That’s why it pays to choose a catheter provider like Urology Pros that’s got your back and specializes in providing Medicare-covered catheters.
We know the process really well and keep ourselves up-to-date with the latest Medicare guidelines. Just call us and give us your doctor's info, Medicare card, and supply list — and we’ll take care of setting everything up. We’ll work directly with your doctor’s office to obtain the necessary prescription and documentation while ensuring Medicare compliance.
If you’re interested in trying other supplies, we can send you samples of all Medicare-approved catheters, too. And if you find one that you like, we're happy to provide that as well. Call us today to speak to your personal service representative and learn how we can help you!
