How to Reimburse Intermittent Catheters with Insurance

There are two main ways to get your intermittent catheters reimbursed—through Medicare or private insurance. Insurance coverage of catheters and supplies varies with each person’s plan, whether private or government-sponsored. To get reimbursement, doctors must provide a prescription since catheters are not sold over-the-counter or for self-diagnosis and self-treatment purposes.

Getting Catheters Reimbursed through Medicare

Medicare benefits under Medicare (Part A and B) or a Medicare Advantage plan may cover intermittent catheters under specific circumstances, such as having underlying diseases or conditions. Medicare Part A is the coverage for inpatient hospital services and may cover the cost of catheters used when you are officially admitted into a Medicare-approved hospital. Medicare Part B covers outpatient care, home healthcare, doctor’s services, and durable medical equipment—intermittent catheters are considered durable medical equipment.

Recipients of Medicare who require catheters as part of their permanent medical conditions usually have catheters and supplies covered as prosthetics.

Recipients who have purchased a Medigap (Medical Supplement insurance) may have additional coverage for out-of-pocket expenses, such as coinsurance, copayments, or deductibles.

Medicare pays only for services that they deem medically necessary. The criteria for medical necessity are:

• Appropriate and needed for diagnosis, or treatment of your medical condition.
• Are provided for direct care and treatment of your medical condition.
• Meet the standard of care in the medical community
• Not primarily for the convenience of you or your doctor.

Paperwork

In order for Medicare to cover urology supplies, you will need to submit at least two forms of paperwork. The paperwork will be in one of  two categories:

1. Physician’s Order:

The most common document required for catheter coverage by medicare is a Physician’s Order or prescription. You must have a Physician’s Order to cover all urology products. 

2. Medical Records:

Medical Records contain the medical history of a patient. They include notes from office visits, lab tests, surgeries, and medications. 

Urology Supplies Covered by Medicare

Medicare provides coverage for a wide range of urology products. Coverage may vary depending on your doctor’s orders:

• 200 intermittent catheters per month—must have doctor’s orders and medical records (coudé may need a special order)
• One indwelling catheter per month with doctor’s orders in latex, silicone, 2-way, and 3-way catheter styles
• 35 condom/external catheters per month with a doctor’s orders and records
• Two drainage bags (leg bag or bedside bag) per month
• One irrigation tray & syringe per month
• 500 ml of sterile water per month
• 10 medical tapes per month
• Does not cover gauze, skin barriers, and gloves

Advanced Beneficiary Notice (ABN)

An Advance Beneficiary Notice of Noncoverage  (ABN) is a notice that alerts people to the chance that Medicare may not cover their supplies.

Receiving an ABN does not mean you can’t get supplies. It lets you know that if Medicare doesn’t provide coverage, you would be responsible for paying the cost yourself.

Getting Catheters Reimbursed through Medicaid

It will vary state by state because Medicaid is state-run, whereas Medicare is federally funded. It will likely be very close to the Medicare program and will require paperwork and doctor’s prescription. Eligibility is based on the level of income but you can be under the poverty level and still not qualify for the state’s program. If you do, you may also qualify for Social Security Income if you have permanent disabilities.

Getting Catheters Reimbursed through Private Insurance

Private insurance plans differ depending on your plan and the insurance company. The only way to get an accurate quote is to call your plan’s customer service department and ask. Some out-of-pocket cost, co-pay, or deductible is typical. Many private insurance plans cover advanced catheter products such as closed system catheters, ready-to-use travel catheters, or hydrophilic catheters. 

What are HCPCS Codes?

 The Healthcare Common Procedure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products, and services a medical practitioner may provide to Medicare members or people with private health insurance. Doctors report the services or supplies they’ve given in HCPCS or CPT codes to Medicare or private insurance for billing and reimbursement purposes.  HCPCS codes primarily correspond to services, procedures, and equipment not covered by CPT (Current Procedural Terminology), which includes durable medical equipment, prosthetics, ambulance rides, and certain drugs and medicines.

The HCPCS code for urinary intermittent catheter is A4353.

If all of this feels overwhelming, CompactCath is here to help 

CompactCath is a catheter company that produces super-compact, pre-lubricated and drip-free intermittent catheters that are ideal for both work and adventure, fitting discreetly into your back pocket, purse, and carry-on luggage. Our team works with a variety of insurance providers and durable medical equipment distributors to get the best rates for you. One of our friendly representatives will help you figure out insurance coverage, billing, shipping, costs, and more. 

If Medicare or your private insurance company does not cover intermittent catheters (or does not cover the needed quantity) we will give you an estimate of what the supplies cost and a 40% discount on your first order.

Call us at (888) 933-2284 and let our CompactCath team help you.

Get free catheter samples

CompactCath has sizes 12-16fr in straight and coude. Try out all three of our products—CompactCath, CompactCath LITE, and OneCath, which are available straight and coudé from 12 to 16 french.