Will Medicare pay for catheters?

Does Medicare cover urological supplies or bathroom equipment? Specifically, does Medicare cover catheters? Also, does Medicare pay for PureWick or other specific catheter brands?

In short, Medicare will pay for catheters. The program will cover much of the cost, and any private health insurance plan you have may cover the rest.

That said, Medicare coverage for the type of urinary catheters you need depends on a few factors, like whether you are staying in a hospital and whether your condition is permanent. In any case, your usage of a catheter must have the guidance of a doctor that participates in Medicare.

Read on to know more about when Medicare covers catheters and what you can do to get Medicare to pay for related medical supplies. And if you want to find quotes from Medicare providers in your area right now, you can enter your ZIP code into our free quote tool above.

When does Medicare cover catheters?

You may need to undergo catheterization if you:

• Have urinary incontinence (you cannot control when you urinate) or cannot urinate when you need to.
• Require surgery on your prostate or in the genital region.
• Have a medical condition like dementia, multiple sclerosis, quadriplegia, or other spinal cord injuries.

Original Medicare (Parts A and B) will cover the costs for catheter supplies in each of these circumstances. Medicare Part A will cover your expenses for surgery should you need to undergo urinary catheterization during an inpatient treatment at a hospital.

Part B, the medical coverage portion of Original Medicare, covers part of the cost for your medical supplies if you need outpatient catheterization. Part B’s catheter coverage generally falls under the durable medical equipment category.

How much of the cost for catheters does Medicare cover?

Medicare Part B covers up to 80% of the costs, and the health care program will only cover equipment from participating suppliers. Your physician must prove that your catheter use is medically necessary. You will pay the remaining 20% of costs, plus your monthly Part B payments.

Does Medicare Advantage cover catheters also?

And what about Medigap policies? If you are signed up with Medicare and have a medical reason for using a catheter, you will have Medicare catheter coverage.

Medicare Advantage (Part C) plans will grant you much of the same coverage that Original Medicare recipients have. Also, the health care plan you choose may cover all or most of your out-of-pocket costs, and you may have to meet a deductible first. The same is true with a Medigap policy.

What types of catheters does Medicare cover?

For outpatient care or patients who need a permanent prosthesis, Medicare Part B will generally cover:

• One indwelling catheter per month. An indwelling catheter is one that a nurse or physician inserts into the bladder through the urethra. The catheter drains urine from the bladder into a colostomy bag.
• Up to 200 single-use, sterile, intermittent catheters a month. An intermittent catheter is a tube that you, a physician, nurse, or caregiver can insert into your urethra to collect urine. You must remove the tube immediately after use.
• Up to 35 condom catheters a month. Condom catheters are external catheters for men who experience incontinence.

Note that you can receive necessary lubricant packets with the intermittent catheters.

Also, you can get a coudé catheter with a prescription. A coudé catheter is a curved-tip catheter that can pass more easily through a male’s urethra.

Does Medicare cover female external catheters as well? Specifically, does Medicare cover PureWick? Medicare will pay for female external catheters from participating suppliers, but it may not cover PureWick.

The BD Purewick Urine Collection System is for women. However, if asked, “Is PureWick covered by Medicare?” a BD representative may tell you that the company works through an exclusive distributor, Liberator Medical. For now, patients are responsible for paying all costs.

How do you get Medicare to cover your catheters?

As with any other type of DME, you must follow these steps to get Medicare to cover a catheter:

• Visit a doctor that participates in Medicare and get a prescription.
• Get a referral for a supplier that also works with Medicare.
• Present additional documentation when necessary. You may need to present this documentation if Medicare initially denies your request and you need to appeal.

For more information about Medicare insurance and the process for getting Medicare medical equipment coverage, call 1-800-MEDICARE (1-800-633-4227).

We hope you have learned much about when Medicare covers catheters and how you can start the process to get Medicare free supplies coverage. There are just a few additional things worth noting in regards to Medicare’s urinary catheter coverage.

According to a pertinent Local Coverage Determination from the Centers for Medicare and Medicaid Services, to get Medicare coverage for urinary supplies, each item must:

• Be eligible for a defined benefit category under Medicare.
• Be deemed a reasonable and necessary treatment for a diagnosis of an illness or injury.
• Meet any other applicable legal and regulatory requirements under Medicare.

Also, the CMS defines “reasonable and necessary” based on provisions from the Social Security Act.

A catheter is considered to be durable medical equipment (DME) if it fulfills the following requirements:

• Withstand repeated use and have an expected lifetime of at least three years
• Be medically necessary.
• Be fit for use in your home.

Under this definition, DME includes things like wheelchairs, in-home scooters, and commode seats. However, many one-use medical supplies will not have Medicare coverage. Catheters are an exception if they serve as prosthetics.

Now, if you would like to see rates from insurance companies that participate in Medicare, you can enter your ZIP code into our free quote tool below.

Case Studies: Medicare Coverage for Catheters

Case Study 1: John’s Experience

John, a Medicare beneficiary, suffers from a chronic bladder condition that requires the use of catheters. He sought reimbursement for the catheters he purchased out-of-pocket. After filing a claim with Medicare, John was pleased to discover that Medicare Part B covered the costs of intermittent catheters, which are considered medically necessary for his condition.

Case Study 2: Sarah’s Situation

Sarah, a Medicare Advantage plan member, relies on catheters for her daily living due to a spinal cord injury. When she contacted her plan’s customer service to inquire about catheter coverage, she learned that her plan provided coverage for catheters under durable medical equipment (DME). Sarah was relieved to know that her Medicare Advantage plan would assist in meeting her catheter needs.

Case Study 3: Michael’s Challenge

Michael, a Medicare Part D enrollee, needed catheters for post-surgery care. Although they were not initially listed as covered items in his prescription drug coverage, Michael contacted his Medicare Part D plan’s pharmacy department and learned that certain types of catheters were covered under specific circumstances, such as when prescribed by a healthcare professional.

Case Study 4: Lisa’s Complex Case

Lisa, a Medicare beneficiary with a complex medical condition, needed specialized catheters. Due to the unique nature of her condition, prior authorization was required from Medicare for coverage. After providing the necessary documentation, Lisa’s healthcare provider obtained approval, and Medicare covered the specialized catheters she needed.

Case Study 5: Robert’s Reimbursement

Robert, a Medicare Part A and Part B enrollee, had to undergo surgery that involved the use of indwelling catheters. He sought reimbursement for the catheter costs and was informed by his healthcare provider that Medicare would cover the expenses, as long as they were deemed medically necessary and prescribed by a healthcare professional.