Medicaid is the nation’s public health insurance program designed for individuals and families who may be low-income, elderly, or disabled. The Medicaid program covers more than 1 in 5 Americans, including many with complex and costly needs for care. With over 74 million Americans relying on Medicaid, it is the largest single source of health coverage in the U.S. The program ensures that qualifying individuals can access medically necessary products, including incontinence supplies, urological supplies, and other medical necessities, as well as healthcare and long-term care services.
Urinary incontinence is a prevalent condition that impacts over 25 million people in the U.S., including more than half of all seniors. Managing incontinence can be challenging, especially for those on a limited income, as the cost of incontinence briefs, underpads, and other bladder control supplies can quickly add up.
Fortunately, for many individuals on Medicaid, coverage is available for the medical supplies needed to effectively manage incontinence, provided there is a qualifying medical diagnosis. This coverage ensures that individuals receive the necessary products to maintain their health and quality of life.
Who Qualifies for Medicaid Benefits?
Medicaid primarily serves three groups: individuals with disabilities, low-income families, and low-income older adults. The majority of Medicaid spending is allocated to long-term and acute care for older adults and individuals with disabilities.
While the federal government sets broad eligibility and benefit requirements, states administer the Medicaid program with some flexibility under federal guidelines.
What Incontinence Supplies Are Covered by Medicaid?
As with other Medicaid benefits, coverage for incontinence products varies by state, including the types and brands of products covered. Most states cover youth diapers and generic incontinence product brands; others may only cover pull-on underwear and adult diapers/tape-tab style briefs. However, most states cover some combination of disposable briefs, pull-on underwear, bladder control pads, reusable and disposable underpads, and other medically necessary incontinence products.
Medicaid covers incontinence supplies for the elderly, disabled, or children with complex healthcare needs. Coverage for incontinence supplies under Medicaid usually begins for children around the ages of 3-4, as this is when they typically develop self-toileting skills.
The best way to find out which incontinence products are covered under your state’s Medicaid program is to contact your Medicaid plan or a Medicaid incontinence supplier.
How to Get the Supplies You Want
A good place to start is to talk to your physician about the type of incontinence products covered by Medicaid. If you’re new to incontinence, let your doctor know so they can provide you with more information and recommend a range of products.
Doctors are trained to assess your specific condition and recommend products that best manage your symptoms while considering factors like your level of mobility, skin sensitivity, and the severity of your incontinence.
Your doctor can guide you on the type of incontinence products that would be most effective for your situation, whether that’s adult diapers, pull-on underwear, bladder control pads, or underpads. They can also help you understand how frequently you might need to change these products, and what additional items, like skin care wipes or barrier creams, might be beneficial to prevent irritation.
Moreover, your doctor’s recommendation will be crucial if you are seeking coverage for these supplies through Medicaid, as they can provide the necessary prescription or documentation, such as a Letter/Certificate of Medical Necessity, to ensure that you receive the appropriate products under your plan.
Why is a Prescription Needed for Medicaid to Cover Incontinence Supplies?
An individual needs a prescription from their doctor to have incontinence products covered by Medicaid. This requirement is in place because Medicaid covers only medically necessary supplies and services. A prescription serves as formal documentation from a healthcare provider, verifying that the incontinence products are essential for the individual’s health and well-being due to a specific medical condition.
The prescription generally includes a diagnosis, details about the type of incontinence supplies needed, and the estimated quantity required. This information helps ensure that Medicaid funds are used appropriately, and that the individual receives the correct products for their condition. Additionally, some states may require additional documentation, such as a Letter/Certificate of Medical Necessity or prior authorization, to further confirm the need for these supplies.
Some Medicaid plans require a doctor’s prior authorization for coverage of incontinence supplies. Prior authorization is a process where the healthcare provider must obtain approval from Medicaid before the prescribed incontinence products can be covered. Prior authorization helps Medicaid maintain quality control, ensure appropriate use of resources, and provide necessary products to those who genuinely need them.
If you find the process overwhelming, your medical supply company can help sort out all the rules and regulations. They are experienced at working directly with individuals, caregivers, and case managers to navigate insurance provider requirements and state-specific guidelines.
Are Incontinence Supplies Covered through a Medicaid Waiver Program?
It is possible to get incontinence supplies through your case manager with a Medicaid waiver, but it depends on the specific type of waiver and the state you live in. Medicaid waivers are designed to provide services that help individuals stay in their homes or community settings, rather than being placed in institutional care.
Many Medicaid waiver programs, such as Home and Community-Based Services (HCBS) waivers, cover incontinence supplies as part of the benefits offered to eligible participants. These supplies can include items like adult diapers, liners, underpads, and wipes.
To access these supplies, you would typically need to:
- Discuss with Your Case Manager: Your case manager can help determine if incontinence supplies are covered under your specific Medicaid waiver program. They can also guide you through the process of getting the supplies approved.
- Obtain a Prescription: In many cases, you may need a prescription or a letter of medical necessity from your healthcare provider to demonstrate that the supplies are medically necessary.
- Coordinate with Suppliers: Once approved, your case manager can help you coordinate with a Medicaid-approved supplier to get the necessary incontinence products delivered to you.
The availability and specific process may vary by state, so it’s important to work closely with your case manager to understand your options.
Does Medicare Cover Incontinence Supplies?
Medicare is a separate program from Medicaid. Medicare is a federal program that provides specific healthcare coverage for people over the age of 65, certain younger individuals with disabilities, and people with end-stage renal disease. Unlike Medicaid, Medicare typically does not cover incontinence supplies. Incontinence products like adult diapers, bladder control pads, pull-on underwear, or underpads, generally must be paid for out-of-pocket under Medicare.
Medicare’s coverage is focused on treatments, services, and equipment that are considered medically necessary to treat or manage health conditions. While incontinence supplies are essential for managing daily life for many individuals, they are categorized as personal hygiene products rather than durable medical equipment or necessary medical treatments under Medicare’s guidelines.
Since Medicare doesn’t cover incontinence supplies, members typically need to explore other options:
Out-of-Pocket Purchase: Most Medicare beneficiaries purchase incontinence supplies out-of-pocket. These products are widely available at pharmacies, medical supply stores, and online retailers.
Medicaid for Dual-Eligible Individuals: If a Medicare beneficiary also qualifies for Medicaid (known as being “dual-eligible”), Medicaid may cover the cost of incontinence supplies depending on your state’s Medicaid program and coverage criteria.
Medicare Advantage Plans: Some Medicare Advantage (Part C) plans, which are offered by private insurers, might offer additional benefits beyond what traditional Medicare covers. This could include coverage for incontinence supplies, but it varies by plan, so you would need to check with your specific plan provider.
Local Assistance Programs: Some states or local community organizations provide assistance with incontinence supplies for seniors or those with disabilities. These programs vary widely, so it’s worth checking local resources.
Understanding these options can help Medicare beneficiaries find the support they need to manage incontinence effectively, even if it means looking beyond Medicare for coverage.
Selecting Your Incontinence Supply Provider
Selecting a medical supply provider that can bill Medicaid for the incontinence supplies you need involves several important steps to ensure that you receive the correct products and services. Here’s a guide to help you make an informed decision:
Check Medicaid Enrollment:
- Verify Provider Enrollment: Ensure the medical supply company is enrolled as a Medicaid provider in your state. Not all suppliers can bill Medicaid directly, so it’s essential to confirm that the provider is authorized to do so.
- Contact Medicaid: You can contact your state’s Medicaid office or visit their website to get a list of approved incontinence supply providers. This ensures that any supplier you choose is recognized by Medicaid and can bill your plan directly.
Evaluate Product Selection and Quality:
- Check Available Products: Make sure the supplier offers a range of incontinence products that meet your specific needs, such as adult diapers, pull-on underwear, pads, or underpads. The quality and comfort of these products are important, so look for brands that are known for reliability.
- Request Samples: Many suppliers will offer complimentary samples of their products. This allows you to try different options before committing, ensuring the products meet your comfort and absorbency needs.
Consider Customer Service and Support:
- Assess Customer Support: Choose a provider with strong customer service. This includes having knowledgeable representatives who can answer questions, assist with product selection, and help navigate the Medicaid billing process.
- Look for Assistance with Paperwork: Some suppliers offer services to handle all necessary paperwork with your insurance and healthcare provider, streamlining the process for you.
Review Delivery Options:
- Check Delivery Services: Confirm that the provider offers discreet and reliable delivery services to your home. Timely delivery is important to ensure you always have the supplies you need.
- Consider Automatic Reordering: Some companies provide automatic reordering services, ensuring you never run out of supplies. This can be especially helpful for managing long-term conditions.
Read Reviews and Get Recommendations:
- Research Reviews: Look for online reviews and testimonials from other Medicaid recipients. This can provide insights into the experiences of others and help you gauge the reliability of the provider.
- Ask for Recommendations: You can also ask your doctor, case manager, or other healthcare professionals for recommendations on reputable suppliers they have worked with in the past.
Verify Billing and Coverage:
- Confirm Medicaid Billing: Before finalizing your choice, double-check that the provider will handle the Medicaid billing process on your behalf. This includes ensuring that they will only bill for the products you are eligible for under your Medicaid plan.
- Understand Costs: Ask about any potential out-of-pocket costs that may not be covered by Medicaid, such as upgraded products or additional supplies beyond what Medicaid covers.
By following these steps, you can select a medical supply company that not only meets your incontinence care needs but also ensures a smooth process for billing Medicaid, providing you with peace of mind and reliable access to the products you require.
ActivStyle: Your Medical Supply Advocate
As a Medicaid-reimbursed incontinence care supplier for nearly 30 years, ActivStyle is a top choice among clinicians, case managers, caregivers, and individuals. We take pride in offering high-quality, comfortable, and reliable incontinence products that are shipped discreetly to our clients. ActivStyle provides a full line of superabsorbent incontinence products, from youth to bariatric sizes, including adult diapers/tab-style disposable briefs, pull-on underwear, booster pads, underpads, wipes, and more. We provide full coordination of services from verifying your insurance coverage for the supplies requested, securing the necessary documentation from your doctor, billing your Medicaid plan on your behalf, and discreetly shipping your product to your door each month. Our Provider Services team is also uniquely trained to work with case managers and other providers who are working with individuals wanting to access incontinence supplies through a Medicaid waiver program.
Complimentary Samples
Interested in trying a complimentary sample of our Medicaid-covered products? This is a great way to explore the best incontinence products available. Whether you’re new to incontinence or looking to try different options, sampling our products is an excellent way to discover what works best for your needs.
To receive complimentary incontinence product samples for evaluation, visit ActivStyle.com and complete our sign-up form. One of our trained experts will reach out to determine if your Medicaid plan covers the necessary supplies. We’ll then discreetly ship the samples to your door for you to try at home.
