OSTOMY SUPPLIES

Medicare coverage and reimbursement for ostomy supplies varies by healthcare setting. Please see the definitions below to identify your setting:

• Residing at Home
• Home Health Care
• Nursing Home

RESIDING AT HOME

Eligibility
You may qualify for Medicare Part B coverage if you:

• Reside at home and are not receiving Home Health Care
• Reside in a nursing home and do not meet the skilled nursing guidelines for Medicare Part A
• Reside in an Assisted Living Facility

First, you should know that Medicare policy requires retailers that provide you with your ostomy supplies and to bill Medicare for reimbursement on your behalf. Second, Medicare provides two billing options for retailers to collect payment: Assignment and Non-Assignment. Third, all ConvaTec ostomy supplies are covered by Medicare.

The guidelines below outline your benefits as a Medicare beneficiary with an ostomy, and are taken from the DME MAC Medicare Ostomy Policy.

Ostomy Coverage
Ostomy supplies are classified as prosthetic devices and are covered for use on patients with a surgically created opening (stoma) to divert urine, or fecal contents outside the body. The type of ostomy, its location, its construction, and the condition of the skin surface surrounding the stoma determine the quantity of ostomy supplies needed. There will be variation according to individual customer need and those needs may vary over time. Ostomy coverage is outlined below. To review the complete DME MAC Ostomy Policy, contact the DME MAC for your state of residence and “Search” for Ostomy Policy.

Physician Order
The ostomy supplier generally takes the responsibility of obtaining the new physician order. Click here for sample order form that provided retailer with information required for billing. An order is required when any of the following occurs:

• The initial claim to Medicare for a new ostomate
• An increase in the amount of supplies is needed
• A change in the type of supplies being billed
• If you choose to alternate between drainable and closed pouches

Utilization Guidelines
The type of ostomy, its location, and the condition of the skin surrounding the stoma determine the quantity of supplies dispensed. Medicare has established utilization guidelines for each type of supply and the amount Medicare will routinely cover on a monthly basis. If the required amount is higher than the guidelines, then a statement of medical necessity is required from a physician.

Categories and HCPCS Codes
Ostomy products are classified into generic descriptive categories and each category is assigned an alphanumeric HCPCS Code. The HCPCS code is based on the supply description regardless of the manufacturer. The HCPCS Code is used when billing for your ostomy supplies. Click here for HCPCS Codes for ConvaTec products.

Allowable Fee Schedule
An allowable fee is established for every ostomy HCPCS Code. The allowable fee is the value Medicare has set for each product category. The fee amount varies by the type of pouch, and skin barrier. Payment of the allowable fee is the shared responsibility of Medicare and the beneficiary:

• Medicare responsibility – 80% of allowable fee
• Beneficiary responsibility – 20% of allowable fee

Medicare allows the supplier to dispense and bill up to 3 months of supplies at a time for beneficiaries residing at home or an Assisted Living Facility. The supplier is allowed to bill only 1 month of supplies for residents of nursing homes.

Suppliers submit claims to one of four (4) insurance companies, called DME MACs contracted by CMS to process Medicare Part B claims. Each of the four (4) DME MACs service a specific geographic area, based on your permanent residence.

Medicare Payment
Medicare provides two billing options for retailers to collect payment: Assignment and Non-Assignment.

Medicare Assignment:

• Supplier must be a Medicare Provider
• Supplier accepts the Medicare Allowable as Payment in Full
• Supplier submits claim to Medicare and is directly reimbursed 80% of the allowable fee
• Supplier collects the remaining 20% of the allowable fee from beneficiary
• No additional money can be collected from the beneficiary for this transaction

Medicare Non-Assignment:

• Supplier must be a Medicare Provider
• Beneficiary purchases products at the supplier’s retail price as a “cash” transaction
• Supplier is obligated to submit a claim to Medicare on behalf of the beneficiary
• Claim must be filed within one year of the date of service
• Medicare issues a check for 80% of the allowable fee directly to the beneficiary
• The beneficiary total expense is the difference between the “cash” transaction price and 80% of the allowable fee amount
• No fee can be collected for filing a claim

The Medicare benefit is applicable for both assigned and non-assigned claims.

For more information regarding reimbursement for ConvaTec products or if you have questions about selecting a supplier in your area, contact the ConvaTec Customer Interaction Center at 1-800-422-8811.

The reimbursement information provided by ConvaTec is intended to provide general information relevant to coding and reimbursement of ConvaTec's products only. Coverage and payment policies for the same insurer such as Medicare can vary from one region to another and may change from time to time because of ongoing changes in government and insurance industry rules and regulations. Therefore, please confirm HCPCS Codes with your local DMERC before processing claims. ConvaTec does not guarantee coverage or payment of its products.

HOME HEALTH CARE

Eligibility
As a beneficiary, it is your responsibility to notify your retailer that you are receiving home health care at the time of purchase of medical supplies. You are under your home health benefit if you receive any of the following in your home: part-time skilled nursing care, physical therapy, occupational therapy, speech therapy, home health aide services, or medical social services.

Ostomy Coverage
The Medicare regulations state that it is the responsibility of the home health agency to provide ostomy supplies from the first visit through the last visit. Medicare will deny claims to retailers for all ostomy supplies provided directly to beneficiaries and billed to Medicare during their home health episode of care. Determining eligibility prior to the transaction will help reduce the risk of denials.

NURSING HOME

Medicare Skilled Nursing Facility:

Eligibility
If you receive skilled nursing care after a related 3-day inpatient hospital stay, you are covered under Medicare Part A. Your Medicare Part A benefit is in effect up to 100 days, as long as you meet the skilled care guidelines.

Ostomy Coverage
All ostomy supplies are provided by the nursing home.

Medicare Non-Skilled or Assisted Living:

Eligibility
If you reside in a nursing home and do not meet the Medicare Part A skilled care guidelines, or reside in an Assisted Living Facility.

Ostomy Coverage
Your Medicare Part B benefit covers your ostomy supplies, under the same guidelines as Residing at Home.