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Depending on the type of insurance you have, you may be able to get your intermittent catheter supplies covered. If you have a spinal cord injury that requires you to catheterize, it’s important to know your various insurance options.
Navigating insurance coverage, including Medicare, can be challenging. If you have an ongoing need for intermittent catheter supplies, it’s important to understand your healthcare insurance options. Otherwise, the costs could take a toll on your finances.
In part 1 of this 2-part series, we focused on how doctors, suppliers, and insurance plans categorize intermittent catheter supplies using the Healthcare Procedure Coding System (HCPCS). We also went over your choices within the three relevant HCPCS codes. In this article, we’re going to discuss specific insurance plans.
Insurance options for intermittent catheter coverage – a snapshot
For most people with a spinal cord injury in the US, healthcare insurance options for coverage of intermittent catheters include Medicare, Medicaid, or private insurance companies. Below is a brief overview of each:
|Insurer||Federal government||Federal and state governments (joint program)||Private insurance companies|
|Overview||A federal system of health insurance for certain younger people with disabilities, as well as for people over 65 years of age||Provides help with medical costs for some people with low incomes and limited resources||Offered to the general public with rules and requirements varying by each insurer (governed by healthcare laws)|
|Eligibility|| — Must be a permanent resident of the US
— You or your spouse worked and paid taxes 10+ years
— 65+ years of age
— Under 65 years of age but have collected Social Security Disability Insurance for 2+ years
|Medicaid has extensive rules for determining an individual’s income and resources to be eligible for the program. In addition, eligibility varies from state to state.||Eligibility varies by plan, but requirements under the Affordable Care Act (ACA) rules mandate private insurers cannot deny you for a pre-existing condition|
|Plan coverage for intermittent catheters||Uniform and consistent rules governing coverage of urological supplies||Coverage varies from state to state||Coverage varies by company and each individual plan|
|Additional details||Individuals can purchase Medicare supplement or Medicare Advantage plans from private insurers for out-of-pocket costs and other healthcare expenses that may not be covered||Medicaid is the only national program that pays for a full range of services that help individuals with disabilities to live in their own homes and communities. Most states, however, spend 70% or more of their Medicaid funding on nursing homes.||Premiums, out-of-pocket costs, copayments, and deductibles all vary by plan, so shopping around is vital|
Medicare coverage of intermittent catheter supplies
Since Medicaid varies by state, and private insurance coverage varies by individual plans, we’ll focus on Medicare, which has clearly-defined criteria for intermittent catheter supplies.
Fortunately, Medicare will cover intermittent catheterization for people who have urinary retention or incontinence for three or more months. They allow a new sterile catheter for each emptying of the bladder (up to 200 per month, if needed). Below are the HCPCS codes for the different types of intermittent catheter products:.
|HCPCS Code||Intermittent Catheter Type|
|A4351||Straight tip, with or without coating|
|A4352||Coudé (curved) tip, with or without coating|
|A4353||Sterile, single-use catheters (“no-touch”)|
Medicare coverage for straight tip intermittent catheters is straightforward. The need for a curved intermittent catheter, however, must be documented in your medical records. In part 1 of this article, we discussed the additional guidelines that need to be followed for submitting claims for “no-touch” catheters, as well as the criteria for establishing the medical need.
One money-saving tip is to utilize an intermittent catheter supplier that will “accept assignment.” This means that the supplier agrees to accept the Medicare-approved fee schedule as payment in whole. Medicare will pay 80% of the supplier’s fee and the other 20% would be your responsibility. So, working with a supplier under this arrangement may reduce your out of pocket expenses. You don’t have to pay price premiums but you would still have a co-pay (paid either out of pocket or via secondary insurance) and you would be responsible for any deductibles.
Important: Medicare offers a choice of intermittent catheters
Medicare empowers you, as a consumer, to choose from a variety of intermittent catheter products at each HCPCS code level. You can choose the intermittent catheter brand and product that works best for you within each category.
Your choices within the A4351 category vary from unlubricated catheters with separate gel to hydrophilic pre-lubricated catheters. If you qualify for A4353 your choices range from a sterile catheter with a separately packaged sterile kit to an all-inclusive “no-touch” catheter system. Knowing that you have choices, work with your healthcare team and supplier to determine the intermittent catheter that is covered under Medicare and works best for you.
Tips for preventing a Medicare claim denial
It’s critical to ensure that your physician and supplier are working together to gather proper Medicare documentation for your intermittent catheter supplies so your claims won’t be denied. Products that Medicare considers “durable medical equipment,” such as intermittent catheters, must meet the following documentation requirements for proper claim processing:
Your physician and supplier should be familiar with these requirements for proper documentation. Still, it never hurts to check with both parties to make sure all five items have been submitted in your claim.
For more details on insurance coverage, visit our intermittent catheter reimbursement page.
Prior to the use of an intermittent catheter, be sure to read the Instructions for Use for information regarding Intended Use, Contraindications, Warnings, Precautions and Instructions.
And don’t forget that Hollister Secure Start Services is always available to help you navigate the insurance market. Based on your insurance plan, our Consumer Service Advisors can explain your options and answer your questions.
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