How to Reimburse Intermittent Catheters with Insurance

January 12,2023 |
Doctor talking to her patient about intermittent catheters.

Intermittent catheters are medical devices used to help individuals empty their bladders. They may be required due to an underlying medical condition, an injury, or during recovery after surgery. There are different types and sizes of intermittent catheters available to suit various medical conditions and patient needs. These types of catheters are inserted through the urethra into the bladder, allowing urine to drain out of the body. Once the bladder is empty, they’re removed and thrown away. However, intermittent catheters are not available over the counter, so you’ll need a prescription to obtain them. Regardless of why you need an intermittent catheter, the fact that they’re single use can lead to rising medical costs. There are a few different options when looking to get your intermittent catheters reimbursed. The process will differ depending on if you have private insurance, Medicare, or Medicaid. Insurance coverage will also vary depending on your plan, insurance provider, and prescription.

To help, consider the following information regarding how to reimburse intermittent catheters with insurance.


Understanding Medicare Insurance Coverage for Intermittent Catheters

Medicare is a federal government-funded health insurance program in the U.S. that serves individuals who are 65 or older, as well as those with certain disabilities and medical conditions. It’s divided into several parts, each consisting of its own coverage and cost structure. Medicare Part A covers hospital care and is generally free for most beneficiaries. This includes inpatient coverage, and therefore, any intermittent or indwelling catheterization which occurs during your hospital stay. Medicare Part B covers a variety of types of outpatient care, such as doctor’s visits, home healthcare, and a range of durable medical equipment (DME).

In order for catheters to be classified as durable medical equipment, there’s certain criteria that needs to be met. For example, they must be required in order to treat or diagnose your medical condition, not just out of convenience for either you or your doctor. Intermittent catheters must also be provided as a direct form of treatment for your condition and meet the standards of medical care for that specific diagnosis. Your doctor will give you instructions on how to catheterize.

Luckily, if you have a medical condition that requires the use of clean intermittent self-catheterization, the catheters are considered DME. This means that they will be fully covered by Medicare as they’re considered a type of prosthetic that’s required for the emptying of your bladder. There’s also an option to add Medigap to your Medicare coverage, which can help reduce any copayments, coinsurance fees, and deductibles. However, there are stipulations for joining Medigap based on your coverage history so it’s important to work with a representative to fully understand your options.

Different Urology Supplies Covered by Medicare

Individuals who meet the criteria will receive a certain number of products. These can vary based on your prescription and medical history. However, in general, you will receive coverage for:

  • Intermittent catheters
  • External catheters
  • Coudé catheters
  • Indwelling catheters
  • Drainage bags
  • Irrigation trays
  • Syringes and other supplies
  • Sterile water
  • Medical tape

The number of catheters will depend on your doctor’s prescription, but usually it’s capped at 200 intermittent catheters, 200 coudé catheters, 35 external catheters, and one indwelling catheter. Gauze, skin barriers, ointments, and gloves are not covered. Remember, intermittent catheters should never be used more than once and you should always wash your hands before catheterization.

Coverage Requirements Under Medicare

If you need any urologic supplies, such as intermittent catheters, and you currently have Medicare, you’ll need to submit a few items of paperwork. Your doctor will be able to help you with this, or you may receive further guidance from your medical supply company. You’ll need to submit a prescription, or a physician’s order, to receive coverage and you may also need to submit your medical records. These will show the various doctor’s notes, history of lab visits and results, surgeries, and medications to help prove that catheters are necessary for your quality of life.

You should also be familiar with the possibility of an Advanced Beneficiary Notice (ABN). This is a document that may indicate one or more of your supplies aren’t covered by Medicare. You’ll receive an estimate of what the supplies cost and you can either choose to pay the difference or talk to your doctor regarding a new prescription. However, if the prescription cannot be changed, you’ll be responsible for the costs yourself.


Understanding Medicaid Insurance Coverage for Intermittent Catheters

Getting reimbursed for intermittent catheters through Medicaid is a little different. Medicaid is a joint-funded healthcare program between the federal government and individual states. It’s not entirely backed by the federal government, which means that coverage options will vary based on where you live. Medicaid aims to provide health insurance coverage to individuals with low income or limited resources. This means that certain medical services, such as hospital care, doctor’s visits, and prescription drugs are offered, but may not be fully covered. However, if you need intermittent catheters for a medical condition and have a prescription or physician’s order, it’s likely that your coverage will be similar to that in Medicare. Eligibility requirements vary, so it’s important to work with a representative to fully understand your options. You may be under the poverty level and still not qualify for your state’s program, but if you have permanent disabilities, you can also look at Social Security Income to help.


Understanding Private Insurance Coverage for Intermittent Catheters

It can be difficult to provide a comprehensive overview for private insurance coverage of intermittent catheters because plans can vary significantly from state to state and provider to provider. The only way to fully understand your coverage options is to talk to a representative from your insurance provider or review your policy in detail. Although coverage varies between providers, they also vary between the plans you have. For example, someone with Blue Cross Blue Shield Preferred Provider Organizations (PPO) may have full coverage for intermittent catheters, while someone with Blue Cross Blue Shield Point-Of-Service (POS) may not.

The primary differences between different private plans tend to be the out-of-pocket costs, co-pays, and deductibles that are included. However, many private insurance policies do provide a degree of catheter coverage that typically includes a closed system catheter or hydrophilic catheters. Coverage details may be dependent upon diagnosis and your doctor’s recommendation.


How to Reimburse Intermittent Catheters with Insurance

To ensure that your intermittent catheters are reimbursed with insurance, it’s important to understand the Healthcare Common Procedure Coding System (HCPCS). The HCPCS is a universal system of codes used by Medicare, Medicaid, and several private insurance groups. However, always double check codes with your provider to avoid any mistakes in processing. These codes are used in place of technical names for several different procedures, products, services, supplies, and more. They help medical providers and practitioners categorize and document for insurance purposes. These codes will be provided to you by your doctor or healthcare provider in order to use them for reimbursement. Many codes are reserved for durable medical equipment, ambulatory services, prosthetic devices, and some drugs or medications. The current HCPCS code that’s used for intermittent catheters is A4353.

In some instances, you may need to pay first then submit a claim to your insurance provider. In others, you can simply show your insurance card upon leaving your appointment and the medical practitioner will bill them directly. If you plan to order supplies, it’s important to find a reputable medical supply company like Byram Healthcare.

Byram Healthcare is one of the leading medical supply companies in the country. We work with Medicare, Medicaid, and most private insurances to help you get the most out of your healthcare plan. Byram provides a better patient financial experience because we’re in-network with over 260 million covered lives. This translates to lower copays and deductibles. Learn more about our mission or browse our intermittent catheter product catalog today.

Byram Healthcare is a member of the National Association for Continence’s Trusted Partners Program, whose mission is to provide quality continence care through education, collaboration and advocacy. We continue to build partnerships in the clinical community to ensure we focus on what’s best for the patient.