From North Central Oklahoma Ostomy Outlook March 2016 (updated Nov 2022):

Medicare Rates for Ostomy Supplies (Updated for 2022)

Based on information distributed by James Knight at our meetings in Feb 1999 and Feb 2003; updated many times by Bob Baumel, most recently in Nov 2022

We published the earliest versions of this article in 1999 and 2003, based on information assembled by James Knight, the proprietor of Knight Medical Supply. Since then, we’ve updated this information periodically. This version is current as of 2022.

Ostomy supplies are classified under Medicare as DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies). Many DMEPOS products have been subject to a competitive bidding program, which tends to reduce Medicare reimbursement substantially. Ostomy supplies have, so far, been kept out of competitive bidding. See information about competitive bidding on the UOAA site.

The table below lists the HCPCS Codes and Medicare “fees” which govern the reimbursements by original Medicare (Part B) for ostomy products. The “fee” is the Medicare allowable charge; i.e., the amount that Medicare considers the product’s reasonable price. A supplier who accepts “assignment” agrees to accept this amount as payment in full. A supplier who doesn’t accept assignment may charge more than the Medicare fee. Whether or not the supplier accepts assignment, Medicare pays 80% of the “fee.” If the supplier takes assignment, then the patient (and any supplemental insurance) pay the other 20% of the fee. If the supplier doesn’t take assignment, the patient (and supplemental insurance) must make up the entire difference between the amount paid by Medicare and amount charged by the supplier.

These fees are for Oklahoma; some of them differ in other states. The fees for some products haven’t been determined and are listed as zero in the table.

The “Max” column displays the “Usual Maximum Quantity of Supplies” specified by Medicare. These are the quantities that Medicare regards as “usually reasonable and necessary.” For example, the specified numbers of pouches per month are usually 20 for drainable or urinary pouches, and 60 for closed pouches. These aren’t absolute limits, as higher amounts can be covered with adequate medical documentation. In practice, however, when these amounts are exceeded, Medicare often denies coverage first, then requires the patient to provide medical documentation to obtain coverage.

The “Max” quantities aren’t specified for all products; when omitted, the quantities for similar products are usually a good guide. Quantities are normally per month, except when followed by the suffix “/6” indicating a 6-month period. For example, the usual maximum for bedside drainage bottles (A5102) is 2 per 6 months.

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