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About Reimbursement for Continence Products

Purchasing disposable incontinence products is costly. Patients and their caregivers can easily spend hundreds of dollars per year purchasing pull-on absorbent products alone. We understand that purchasing continence products can be an economic hardship, and because of this we are providing you with some ideas on how to obtain reimbursement for products you purchase, along with further resources for locating assistance with the costs associated with using disposable products. We also have provided you with some ideas that, although they will not provide 100% reimbursement, may help you cut your out-of-pocket costs.

There are some circumstances in which continence products may be reimbursed through insurance programs (public and private) or may qualify under certain programs for tax deductions or pre-tax dollars. Because rules and regulations keep changing, always check directly with the insurance agency with whom you are dealing, and also with any retailers you use for purchasing your products who provide help with insurance, Medicare and Medicaid as part of their customer service. Please check with them at least once a year to find out if there have been any recent changes within coverage guidelines for any program for which you may qualify. And always check with your doctor's office to see if the staff there can provide you with any assistance with filing for reimbursement. The doctor's diagnosis is a critical first step in getting coverage.

Medicaid

Medicaid coverage varies from state to state. In some states (not all), Medicaid recipients are eligible for complete coverage of absorbent products. Often the company you order products from can help you figure out if Medicaid will cover your products in your state (assuming you are a Medicaid recipient). In some states, Medicaid has "preferred vendors" through whom you must order your products, so you should call your state Medicaid office directly to see if you need to use preferred vendors.

Note On Intermittent Catheters - The Medicaid program typically will reimburse a person for 120 intermittent catheters per month for those using intermittent catheters. Medicaid covers straight catheters, coude catheters, and catheter kits, as well as most brands of catheters with hydrophilic coating and antibacterial coating. Medicaid uses an authorization process using its own authorization form for the beneficiary’s medical supplier and physician.

Medicare

Medicare is the US government's health insurance program for people age 65 and older, people under age 65 with certain disabilities, and people of any age with end-stage renal disease. Medicare has a wide range of coverage, but does not usually cover absorbent products, but may cover some other urological supplies.

Medicare reimbursement coverage allows intermittent catheter users to be reimbursed for a maximum of 200 sterile, single-use catheters per month. This new policy is subject to the normal standards of medical reasonableness and necessity. The patient will need a doctor's prescription and must have permanent urinary incontinence or urinary retention. In addition, the patient or caregiver must be able to perform the procedure. Also, Medicare will cover closed system intermittent catheters or sterile intermittent catheters with insertion kits when the member has permanent urinary incontinence, and there is documentation that individual meets one of the following criteria: The Medicare member has two distinct, recurrent UTI's while on a program of sterile intermittent catheterization within 12 months of each other; or, the Medicare member resides in an nursing facility; or, the patient is immunosuppresed; or, the patient had a radiologically documented vesico-ureteral reflux while on a program of intermittent catheterization; or the patient is a spinal-cord injured pregnant female with a neurogenic bladder.

Medicare covers commode chairs when ordered by a doctor and for use in your home if you're confined to your bedroom. For information on coverage, click here.

Medicare coverage varies from state to state. There is a website where you can check coverage for your state. To check coverage of urinary incontinence supplies in your state, simply go to http://www.medicare.gov/Coverage/Home.asp, select your state, and then choose "Urological Supplies" from the list of topics.

For further help in determining your benefits, use the Medicare Eligibility Tool.

If you area having difficulties paying for your Medicare expenses, and your income is limited, check out to see if you qualify for the Medicare Savings Program or the federal Extra Help program. To find out if you qualify for either program, you can contact your state's health insurance assistance program (called SHIP). To find your SHIP toll-free phone number, go to shiptacenter.org and select your state.

US Veterans Administration

If you served in the active miliary, naval or air service and are separated under any condition other than dishonorable, you may qualify for health care benefits. Also, current and former members of the Reserves or National Guard who were called to active duty (other than for training only) by a federal order and completed the full period for which they were called or ordered to active duty may be eligible for VA health care. Most Veterans will be asked to complete a financial assessment as part of their enrollment application process. Otherwise known as the means test, this financial assessment is based on the Veteran's previous year gross household income and is used to determine his or her eligibility for VA health care benefits and, in many cases, his or her priority group assignment. VA Prosthetic & Sensory Aids Service furnishes properly prescribed prosthetic equipment, sensory aids and other devices to eligible Veterans.

Healthcare Benefits information booklets and guides are available on the VA website and also by calling 1-877-222-VETS (8387).

The VA also provides allowances, vocational training and rehabilitation, and VA-financed health care benefits to certain Korean and Vietnam Veterans' birth children who have been diagnosed with spina bifida. To find out if you qualify for assistance and about coverage, contact Spina Bifida Healthcare Benefits in Denver, Colorado at 1-888-820-1756 or www.va.gov/hac/forbeneficiaries/spina/spina.asp.

For basic information VA healthcare benefits, read the pamphlet, Veterans Health Benefits Guide.

Private Health Insurance Plans

If you have a private insurance plan, you may want to learn about health savings accounts (HSA). Because most insurance plans will not cover incontinence supplies (check to see if yours does or does not first), it may be to your benefit to switch to a higher-deductible plan so that you can participate in an (HSA). To participate in an HSA you must be under 65 years of age and not enrolled in Medicare, and have a high-deductible heath plan without being covered by other insurance (exceptions are disability, dental, vision and long-term care insurance). HSAs can be used to pay for "qualified medical expenses." Your contributions to the HSA are not subject to federal income tax at the time of the contribution, and your funds roll over and accumulate year to year if not used.

However, there is no definitive list of what constitutes a "qualified medical expense". Insurance coverage alone is not an indicator of whether or not an expense may be covered by an HSA, even though many HSAs are used to pay for medical expenses that are not covered by insurance. Because of this vagueness, and annual changes to qualifying expenses, speak to an accountant, and if your insurance is through your employer, talk with someone in your Human Resources Department, about setting up an HSA to see if your incontinence products would be qualifying expenses. If you do open an HSA after consultation with an accountant and/or your Human Resources Department, make sure that you save all of your receipts and keep a dated and signed letter from your doctor addressing your medical need to purchase incontinence products. Receipts will need to be submitted to the plan administrator to receive reimbursement checks.

Also see IRS publication 969 regarding HSAs on an annual basis.

Another option through Private Health Insurance Plans is a Flexible Spending Account (FSA). With an FSA, an employee sets aside a portion of earnings, which are not subject to payroll taxes, to pay for "qualified expenses." Funds that are desposited into an FSA must be spent during the calendar year. Like an HSA, you should seek advice from your Human Resources Department on what they define as qualified expenses, and specifically if your incontinence supplies would qualify. Save all your receipts throughout the year as they will need to be submitted to the plan administrator to receive reimbursement checks.

Affordable Care Act - The Affordable Care Act will change how some people have insurance coverage. The Act is in the process of implementation. For answers to many questions regarding how this act may or may not impact you, check the government website devoted to information on this new law at Healthcare.gov.

Tax Deductions (IRS Filing)

The IRS publication 502 is helpful in determining each year what medical expenses may or may not be covered for those itemizing deductions on Schedule A for their taxes. This publication is updated annually, and should be referred to each year for changes.

Local/County Offices for the Aging

The local government section of your telephone book will list aging and disability resource centers, where reimbursement and insurance information assistance may be available.

Another way to locate local agencies is by accessing the home page for the Administration on Aging (AoA). There is a Search dialogue box at the top right of the page. Entering "incontinence" and clicking on the Search button will generate a list of pages that deal with the topic of incontinence. In addition, you can use the Eldercare Locator tool to find local agencies that can provide information and referral to help you find needed services and information.

Also use your favorite search engine and use key words such as: your town name, your State, and "area agency on aging" and you will also find numerous pages that will provide you with additional resources.

Diaper Banks

The Simon Foundation for Continence keeps an updated list of known Diaper Banks in the US that should also cover adult absorbent incontinence products. Diaper Banks are run by local agencies and are often working with local food banks. Click this link to review the list of Diaper Banks. To see if your community might have a diaper bank not on the list, check with your local food banks, churches and synagogues, senior centers or agencies, or United Way agencies in your county.

Craigslist

You may find incontinence products for sale on your local Craigslist. Peope sometimes have a few packages, boxes, or partial packages of products that they are offering at a greatly reduced price. Find a regional listing: www.craigslist.org/about/sites

Manufacturers and Distributors

Manufacturers and major distributors of incontinence management products may provide a free sample of a product, but they do not have free product programs. Samples are usually available through their websites or by calling their customer care phone lines for assistance. Go to our Product Listings area to find manufacturers and distributors and their phone numbers to ask about sampling programs.

Website for Overall Elder Care Costs and Assistance (including the costs of medical equipment and supplies)

Paying for Senior Care is a website that has been designed to help aging Americans who are struggling to pay for home care, assisted living and long term care. Paying for Senior Care's mission is to help solve this puzzle by providing tools and information to: 1) find financial assistance for elder care, 2) understand and lower long-term care costs, 3) find affordable home care and assisted living, 4) understand Medicare, Medicaid and veterans benefits, 5) make home modifications to enable aging in place, and 6) find benefits counseling and eldercare financial advisers. Their website also has information on "Financial Assistance for Adults Diapers and other Absorbent Products for Seniors."