United States citizens are living longer, which increases their risk for developing incontinence. Patient advocates and health care providers are hearing about the inability to pay out-of-pocket for needed incontinence management products from a growing number of seniors (65+ years) with incontinence, their caregivers and family members, and insurance case workers. We are well aware of the physical and emotional effects of incontinence, but we may not be as aware of the economic impact on our senior patients. Elderly women are especially hard hit; in addition to the fact that urinary incontinence is much more prevalent in this group, elderly women are historically lower wage earners and as such have a lower social security or fixed income with which to purchase products. Patients new to Medicare are often quite shocked to learn that despite a physician’s diagnosis of stress urinary incontinence, urgency urinary incontinence, mixed urinary incontinence, or fecal incontinence, Medicare will not reimburse for their disposable absorbent incontinence products. Although these are necessary medical supplies for their refractory incontinence symptoms not unlike many other disposable medical products (exceptions exist for disposable diabetes, ostomy, and feeding tube supplies), Medicare does not (and for the foreseeable future, will not) cover them. Likewise, most private insurers do not reimburse for these supplies.
Incontinence supplies for seniors who qualify for Medicaid may be partially to completely reimbursed, and it behooves those who qualify for Medicaid to find out if their state’s program can be of assistance. Currently, 45 states and Washington, DC offer some level of reimbursement for absorbent incontinence products. Each state has its own guidelines and regulations, which are in flux; patients need to contact their state Medicaid office and learn how their state’s program is administered. They must learn which products are covered, how and where they may be purchased, and how pre-authorization works before purchasing products. Patients also must stay abreast of changes to their state Medicaid plans and how those changes may impact them.
Seniors who do not qualify for Medicaid are finding their fixed retirement incomes cannot support the costs of their needed disposable medical supplies. Incontinence supplies can easily cost well over $200 to $300 per month at a minimum. After paying for housing, food, and other necessities of living, these folks often do not have the money to cover the costs of their needed incontinence products. We have heard directly from patients that, “It’s either food, heat, or my incontinence supplies.”
One notable Medicare coverage exception exists for intermittent catheter (IC) users. Medicare reimbursement coverage allows IC users to be reimbursed for a maximum of 200 sterile, single-use catheters per month. This policy is subject to the normal standards of medical reasonableness and necessity. Patients need a doctor’s prescription and must have permanent urinary incontinence or urinary retention. In addition, Medicare requires that the patient or his/her caregiver be able to perform the procedure. Medicare will cover closed system ICs or sterile ICs with insertion kits when a patient has permanent urinary incontinence and meets 1 of the following criteria: the Medicare member 1) has had 2 distinct, recurrent urinary tract infections (UTIs) within 12 months of each other while on a program of sterile IC; 2) resides in a nursing facility; 3) is immunosuppressed; 4) had radiologically documented vesico-ureteral reflux while on an IC program; or 5) is a spinal-cord injured pregnant woman with a neurogenic bladder.
What Can We Do to Help Our Senior Patients Who Cannot Afford Incontinence Supplies?
We know how important it is for patients to use the correct and most appropriate products in order to prevent infection, skin breakdown, and a reduced quality of life. First, we need to make sure our patients are using the correct product(s) for their type of incontinence. Products need to fit correctly, be easy to use, contain the urine/fecal output, and help prevent incontinence-associated dermatitis and UTI. Patients and their at-home caregivers need to understand how to properly use the recommended products. Taking time to help patients know what to look for in a product and how it should work for them is important educational information we can offer.
Second, we need to make sure our patients are working with health care professionals to help reduce the number of incontinence episodes they are having each day/week. Whether strengthening the pelvic floor while working with a physical therapist, getting to a healthy weight with a registered dietitian, working in a smoking cessation program, or trying a medication to reduce nighttime polyuria, professional support to reduce leakage will lessen the need for absorbent product changes and will reduce their product-related costs.
Third, we need to help educate our patients to be smart consumers of incontinence products. Our patients need to know that:
• Many products are more readily available through online vendors than in local big box stores, grocery stores, and drugstores. Online retailers of incontinence products will have a much wider variety of products available than any store.
• Purchasing by the case on a preset schedule through an online vendor will save money. Most suppliers offer discounts on case purchases; when setting up a home delivery schedule, patients may receive an additional discount. Some suppliers offer free shipping. Customers can request discreet packaging (ie, unmarked boxes); most vendors offer this service as a standard courtesy. For patients with mobility issues or who live far from large stores, delivery of product to their homes also can help reduce the ancillary costs associated with their products.
• Comparison shopping among vendors may help patients find items at a lower cost.
• Online vendors often have a program that will allow patients to sample a product before committing to buying a quantity of an item that may not fit or work properly for them. Many patients spend hundreds of dollars purchasing products that do not work out; sample programs help reduce overall costs by helping get patients a product that fits and works without a large outlay of money.
• Some online vendors have specialists who can assist Medicaid recipients and help them get coverage for their product purchases.
• Using manufacturer coupons and rebates may help lower costs. These are available through needymeds.org/coupons-branch, manufacturer websites, and newspaper inserts.
Many seniors cannot afford their products at all and need to find places and resources where they can obtain products for free or at an extremely low cost. In this case, you can advise your senior patients they may find assistance from:
• Local/regional diaper banks
• Salvation Army, Good Will, and similar stores and agencies
• Senior centers
• Local/regional food banks
• US government local agencies on aging (eg, eldercare.acl.gov/Public/Index.aspx)
• Religious social service agencies (eg, Catholic Social Services, Lutheran Social Services)
• US Veterans Administration health care
• US Veterans home and community-based services.
Patients also should be advised to save all receipts for their medical supply purchases, because they may qualify for a tax deduction. Annual Internal Revenue Service (IRS) requirements for qualifying medical expenses should be consulted (IRS annual publication 502).
The increasing economic burden of out-of-pocket medical supply expenses for our senior patients needs to be approached sensitively and delicately as we work with them on finding product solutions. Carefully asking about their ability to pay for their products and making sure they are aware Medicare will not cover the cost of their disposable products can open a conversation in which we can provide valuable information on economic assistance, product selection guidance, and purchasing options.