Question about Medicare coverage of supplies

[jstl]

Happy New Year!
I have kind of a newbie question - I'm not a newbie to ileostomy but I am a newbie to Medicare (January birthday). My question is, how do you get set up for this with one of the suppliers? I've been using SB Medical (Stomabags) for years but they don't bill Medicare so that won't work (though I guess I could file my own claim). Also, are there companies that are better to deal with than others (the reason I started with Stomabags is that I had some issues with one of the big companies years ago)? Thanks for any info that comes my way!

[Mara]

I've always had suppliers that bill Medicare so not sure how to do it directly so maybe the Medicare website has instructions on how to file your own claim.....so you don't have to give up a company you like....

[Mara]

fyi, I have another thought about your issue - it really depends on what your current supplier will charge you.....in comparison to what Medicare pays. Maybe you can look into that so you won't have an unpleasant surprise...

For example I just checked my recent Medicare claim - my supplier charges approximately twice as much as Medicare approves....but no one pays the excess charge....

[Mysticobra]

Oh Ya. Hate those surprise bills.
I just got set up with a new supplier.
Reason bring they quit carrying two items I use.
Byram.
So I went to 180 medical and they set it all up.
I didnt have to do anything.
She said when I'm ready to order.
Just order.
The supplier just sets it up after you give them what insurance you have. And your Medicare info.
My supplies were fully paid by Medicare and my insurance.
Humana. at Byram.
180 said the same. Hope I don't get a "surprise".
Richard.

[Mara]

But the OP said his insurance company does not bill Medicare!

[Bob Webtech]

Hi jstl,

If you're new to Medicare, your first choice is between original Medicare or a Medicare Advantage plan. In a Medicare Advantage plan (also known as Medicare Part C), a private insurance company administers all your Medicare benefits. See a comparison on the Medicare website at https://www.medicare.gov/basics/get-sta ... -advantage

My own choice is original Medicare with a Medicare Supplement (Medigap) plan and a Prescription Drug (Medicare Part D) plan. But the Medicare Advantage plans are heavily advertised and, during the past year, the number of people enrolled in Medicare Advantage plans has overtaken the number in original Medicare. It turns out, however, that Medicare Advantage plans can be problematic when it comes to ostomy supply coverage, as explained in a UOAA Advocacy post at https://www.ostomy.org/open-enrollment- ... important/

On choice of supplier: Although not comprehensive, a page on my local support group website at https://www.ostomyok.org/tollfree.shtml lists some basic options. These include local suppliers (which are sometimes a good choice), full-service mail order suppliers, some discount suppliers (including Stomabags), and a couple of options intermediate between the full-service and discount suppliers. The differences involve "Medicare Assignment" as explained in footnotes on the page. Note that while discount suppliers like Stomabags can be an excellent choice if you don't have insurance, purchases made from that kind of supplier aren't covered by Medicare at all, even if you file the paperwork yourself.

A subtlety about Medicare Assignment which may explain why Byram stopped carrying some items used by Mysticobra: Some suppliers, including Byram, are Medicare "participating" providers, which means they guarantee to take Assignment on every Medicare-covered item they sell. In this case, if the supplier finds that taking assignment on a particular item (which includes charging no more than the Medicare approved price) would require selling at a loss, they simply won't sell that item. Many other suppliers, including the other "full-service" suppliers on the above web page, take Assignment on most of the items they sell, but reserve the option to charge more than the Medicare-approved price for some items, so they don't have to sell those items at a loss.

(By the way, 180 Medical, which Mysticobra uses now, is owned by Convatec, so may be a good choice if you use Convatec supplies, but not if you use other manufacturers' supplies.)

For some more info on insurance and ostomy supply reimbursement, see a webinar that Hollister prepared for UOAA at https://www.youtube.com/watch?v=LzamZ3qiRiE This was posted in August 2018, so the stated rates are a little bit out-of-date, but it includes a basically correct explanation of reimbursement under original Medicare. Also see a recording of a UOAA Ostomy Academy presentation about insurance from October 2023 at https://www.youtube.com/watch?v=AKUS4tsscvs

[Mara]

Very interesting, Bob!! i didn't know that one couldn't file directly with Medicare if their supplier doesn't participate...thanks for explaining. I only once bought from a supplier like that because it was an emergency and I didn't bother thinking about reimbursement....

[Mysticobra]

Bob.
I found that out when I was talking to them.
So I think it will work out well.
I do use convetec..
Richard

[jstl]

Mara, Richard, and Bob,
Thank you all so much for this information. It was very helpful. I'll check out 180 Medical - I'm not familiar with it. Regarding Advantage Plans, yes, my chocie waas to avoid them. I signed up with traditional, along with medigap and part D. I appreciate that you all took the time to respond!

[Mysticobra]

Welcome.
I can't help much.
But if I can. I try.
Richard.

[To Dream a Dream]

A big Thank You to all contributors to this post. I just checked out the 180 Medical (previously unknown to me) website & have flagged it for future reference. At my age, I need all of the options I can acquire. Does anyone know if 180 Medical supports our UOAA? Their site projects a very upbeat positive & progressive attitude.

[Bob Webtech]

Does 180 Medical support UOAA? Well, 180 Medical is a fully owned part of Convatec. So, to the extent that Convatec supports UOAA, 180 Medical might be said to support UOAA. And Convatec is currently a UOAA "Digital Sponsor."

But note that in my earlier post in this thread, I referred to a page of my local support group website at https://www.ostomyok.org/tollfree.shtml which includes a list of suppliers. On that page, I specifically omitted 180 Medical, precisely because 180 Medical is owned by a manufacturer so, as a supplier, it isn't brand-neutral.

Among brand-neutral suppliers that I'm aware of, the one that can best be said to support UOAA is probably Byram. For example, Byram sponsored UOAA's latest Ostomy Academy presentation at https://www.youtube.com/watch?v=AKUS4tsscvs

[Mara]

Interesting about whether a company supports the UOAA - I have never thought of that....

I used to use Byram - for many, many years - back in the day I went to their location in Byram CT to pick up supplies - I am speaking of decades ago. Then a few years ago had an issue with them and switched to Adapt formerly McKesson.

My main hope is that whatever company I use sends the products immediately and bills correctly.....should be easy, right??

[Bob Webtech]

For some more on UOAA sponsors, see https://www.ostomy.org/national-sponsors/

[steiconi]

So I went to 180 medical and they set it all up..
180 said the same. Hope I don't get a "surprise".
Richard.

I've been using 180 medical for several years. The only surprises have been what they decide to send. About half the time, they get my order right. The other half may have missing items or be something entirely weird. Once they sent "kangaroo pouches" (something kangaroo, anyway, completely unrelated to ostomies) instead of the supplies I ordered.

They do eventually sort it out but make sure you have a few weeks supplies as backup, no matter what Medicare says.