Jeanine Gleba, UOAA Advocacy Manager
Sue Mueller, RN, BSN and UOAA Advocacy Committee Co-Chair
The Medicare Open Enrollment Period occurs each year from Oct. 15 to Dec. 7, and this gives consumers the chance to review and make changes to their current Medicare coverage. Many employers also have open enrollment for health insurance during this time period. Health care insurance plans are not equal and the plan you choose can make a difference in the amount and type of ostomy supplies you receive and the companies that provide your supplies. It’s crucial that people living with an ostomy understand their health insurance plan and shop around for the best plan to meet all of their medical needs.
Although UOAA is not in the insurance business and does not give insurance advice, it does listen to our members and respond by taking action. We are committed to preserving your access to the supplies that you choose. UOAA’s Advocacy Committee has submitted federal comments and recommendations to the Centers for Medicare and Medicaid Services (CMS) as well as partnering with coalitions and endorsing policy papers that are used when advocating with healthcare insurance companies and key decision-makers. An example of this is the White Paper that UOAA co-authored and endorsed entitled “The Critical Need to Provide Ostomy Supplies Specific to Patient Need to Improve Health Outcomes”
As you do your research during your open enrollment period or become eligible for Medicare for the first time, be cautious with Medicare Advantage Plans (MC Advantage). These are also known as “Part C” and are a type of Medicare health plan offered by a private company that contracts with Medicare. Learn more about understanding Medicare Advantage plans. According to data (from CMS) over half of eligible Medicare beneficiaries are now enrolled in private Medicare Advantage Plans (1). There are many known problems with these plans such as narrow provider networks, prior authorization requirements and high out-of-pocket costs.
For the ostomy community, although MC Advantage Plans must cover the same medical services and treatments as original Medicare, how much they cover is up to them. Some MC Advantage plans have less ostomy supply coverage than Medicare specifically by restricting where beneficiaries can shop for supplies and what kind they approve. UOAA has found that some ostomy patients with these plans must use products from multiple manufacturers. Some MC Advantage plan benefits exclude Medicare HCPCS (Healthcare Common Procedure Coding System) product codes for ostomy supplies such as filters, tape, adhesives, deodorants and other medically necessary items. What this means is that these supplies are not even available for you to choose.
There are many Medicare Advantage Plans in the United States. Each state’s insurance department approves the MC Advantage plans that can be sold in each state and each county within the state. So the plans vary from county to county. The MC Advantage plans usually have approved national provider networks for supplies however UOAA has found that in some counties the MC Advantage plans limit the suppliers you can use to local providers and do not let their beneficiaries choose from the national network providers. This may result in a limitation of your supply choices. One example UOAA has discovered is the difference in suppliers available in a rural county as compared to the national network provider offered to the residents in a large city.
Some MC Advantage Plans also have much lower reimbursement rates than traditional Medicare. These reduced fee schedules have resulted in suppliers to either stop taking individuals with an ostomy, offer lower quality products or offer a limited product line. (see the policy paper link above).
This practice of restricting beneficiaries to particular brands, specific suppliers or less product coverage, limits patient access to the products they need. The consequence of this practice is that many ostomates are unable to obtain their prescribed ostomy supplies and are no longer able to effectively manage their ostomy.
If you chose a high deductible plan, remember that although you have a lower monthly premium you will be paying out of pocket for all of your ostomy supplies which are expensive until you meet the deductible requirements.
If you aren’t on Medicare but are selecting a new health plan, carefully review “basic” plans on the marketplace. Some of these bare bones plans do not cover ostomy supplies.
For more tips and information refer to the article released by UOAA’s Advocacy Committee entitled “Are You Covered? Know Your Healthcare Insurance and What You Need”. As you compare plan options and shop around, ask questions such as “Can I use my current supplier with this insurance?”. Here are more: 10 Questions to Ask Before You Choose a Health Plan.
1. Freed, Meredith, et al. “Half of All Eligible Medicare Beneficiaries Are Now Enrolled in Private Medicare Advantage Plans.” KFF, 1 May 2023, https://www.kff.org/policy-watch/half-of-all-eligible-medicare-beneficiaries-are-now-enrolled-in-private-medicare-advantage-plans/. Accessed 17 October 2023.