Incontinence Supplies and Medicare Coverage is limited, but not impossible.
Despite the number of people who live with incontinence, traditional Medicare does not cover any incontinence supplies like diapers and pads. However, depending on your financial circumstances and the type of medical insurance you choose, the cost of incontinence essentials may be reimbursed or at least be a tax-deductible expense. Here are the options that may be available to you.
Medicare Advantage Plans
Although Medicare doesn’t cover incontinence supplies, in many states some of the Medicare Advantage plans offered by private insurance companies, like Blue Cross Blue Shield and United Healthcare, do. Usually you’ll need to purchase qualified items through an eligible provider, a company that has been approved to handle claims and will often process them for you. There are limits to how much product is covered on a monthly basis. These limits vary by plan, but are often between 200 and 300 briefs or diapers per month. The types of products that are covered also vary by plan. Some insurance companies divide incontinence products into different categories. According to one major health insurer, bed underpads are only covered if you also need diapers or briefs.
If you’re eligible for Medicaid in your state, your incontinence supplies
may be covered to some extent. Each state has the option to cover incontinence care supplies and related equipment and accessories. Most, but not all, states offer some coverage, and that coverage varies widely from one state to another. Most states that offer this benefit cover disposable adult briefs or pull-ups, bladder control pads or guards, and bed underpads; some states also cover wipes and gloves. Recently, a number of states have taken steps to control their costs by either lowering reimbursement rates or the maximum amount of incontinence supplies covered—and what they do cover can change from year to year, so you need to review the policy yearly.
States require that your physician prescribe incontinence supplies for a medical condition. Your doctor will typically write out a prescription that specifies the quantity of supplies you need on a regular basis, typically monthly.
Your state Medicaid program will dictate how you receive your supplies, either through a participating supplier who submits claims to the state for reimbursement or through a managed-care plan that includes these products as part of their services.
Contact your state Medicaid office to find out if it offers coverage and what rules and limitations are. You can access a complete list of state offices here.
Veterans receiving VA benefits can get incontinence supplies as part of the benefit that covers “medical supplies.” The Pharmacy Service normally provides them on a recurring basis for home care of a diagnosed disability, but some products are available through the Prosthetic and Sensory Aids Service. If the standard issue brand doesn’t provide the absorbency or other features you need, you are able to request better brands. You’ll need to work with your doctor to get a prescription or statement of medical justification that explains the medical reasons for which a specific brand of adult diaper or brief is better for your needs. Research your options online and use free or low-cost sampling
to try different brands to find the one that works best, so you’ll know what to request.
Health Savings Accounts
If you aren’t eligible for Medicaid and aren’t old enough for Medicare yet are dealing with incontinence, the cost of incontinence supplies may be a deductible expense you can pay for with a health savings account (HSA), which is typically part of a high-deductible health plan. HSAs can be used to pay for what the Internal Revenue Service (IRS) determines are “qualified medical expenses.” Incontinence may qualify if it is caused by a diagnosed medical condition. Contributions to an HSA are not subject to federal income tax, and any funds you don’t use can accumulate year after year. Typically, you need to provide receipts for expenses and submit them to the plan administrator to get reimbursed.
Another option is creating a flexible spending account or FSA. As with an HSA, disposable incontinence products are generally covered by medical FSAs if the incontinence is because of a doctor-diagnosed medical condition. An FSA must be set up by an employer, but you determine how much will be taken from each paycheck to fund the account—money that isn’t subject to federal, state, or social security taxes—based on what you project all uncovered healthcare expenses for the coming year will be. You withdraw funds throughout the year as needed to pay for qualified medical costs.
It’s important to work with your human resources manager or the HSA or FSA plan administrator to confirm that the plan available to you offers incontinence products as qualifying expenses.
Steps You Must Take
To get coverage with virtually any of the above options, your incontinence must stem from a diagnosed medical condition. Why? Because according to IRS rules, you can’t include the amount you pay for diapers or diaper services among your medical expenses unless they are needed to relieve the effects of a particular disease. It’s important to keep in mind that incontinence itself is not considered a disease or condition, but rather a symptomor “effect”—of a disease or condition. That’s why you must get a proper diagnosis from your healthcare provider. Incontinence suppliers who send you products and submit claims to Medicaid, for instance, must have the diagnosis code provided by your doctor to do so.
In addition to a set diagnosis, you’ll likely need your doctor to provide a written prescription for your incontinence supplies to show that they are needed to help you manage it. In some situations, it might also help to have a letter written by your doctor explaining your medical situation.
If you buy your supplies directly with funds from a HAS or FSA, keep all receipts as proof of the expenses.