Medicare's coverage for PureWick external catheters: A legal inquiry
Managing incontinence just got a whole lot easier, thanks to the PureWick system – a revolutionary device designed specifically for female users during sleep or rest. This innovative solution includes an external catheter that extends from the vulva to the buttocks, connecting to a tube leading to a collection container placed at nightstand or table.
As of 2024, Medicare stepped in to support this technology under the durable medical equipment (DME) benefit of Part B, following a ruling by the Centers for Medicare & Medicaid Services (CMS). But there are a few conditions to meet.
Medicare Part B, covering essential medical items like oxygen supplies and hospital beds, is the gateway for getting qualifying devices. With a prescription from a Medicare-enrolled doctor or healthcare professional, a patient can access DME for home use. Adding external catheters into the mix, Medicare includes the PureWick system as an alternative to indwelling catheters for individuals diagnosed with permanent urinary incontinence.
However, there's a catch – Medicare won't approve coverage if an individual already has an indwelling catheter. What's more, for female catheters, Medicare limits usage to one metal cup or pouch per week. In a hospital setting, catheters will be covered by Part A.
Now, let's talk costs. According to the manufacturer's website, a box of 30 catheters will set you back approximately $209 without insurance. But buying in bulk can save you a pretty penny. As for Medicare, enrollees must fulfill annual deductibles of $257 and pay a monthly premium of $185. Once these costs are covered, Part B will chip in 80% of the approved treatments or services.
Keep in mind that Medicare Advantage (Part C) plans offer private coverage with varying premiums, deductibles, and coinsurance.
Here's a quick breakdown of some key Medicare terms to help you navigate the joys of catheter coverage:
- Out-of-Pocket Cost: The amount you must pay from your own pocket when Medicare doesn't cover the full cost or doesn’t offer coverage. This may include deductibles, coinsurance, copayments, and premiums.
- Premium: The monthly fee you pay for Medicare coverage.
- Deductible: The annual amount you need to spend out-of-pocket within a certain period before Medicare starts to fund your treatments.
- Coinsurance: The percentage of the treatment costs that you must cover out-of-pocket. For Medicare Part B, this figure usually comes in at a steep 20%.
- Copayment: A fixed dollar amount you pay for specific treatments while insured. Medicare usually requires this for prescription drugs.
- Starting from 2024, the Centers for Medicare & Medicaid Services (CMS) allowed Medicare Part B, which covers essential medical items, to support the PureWick system under the durable medical equipment (DME) benefit.
- For female users with permanent urinary incontinence, the innovative PureWick system, an alternative to indwelling catheters, can be accessed with a prescription from a Medicare-enrolled doctor or healthcare professional.
- Keep in mind that while Medicare Part B may cover 80% of the PureWick system costs once annual deductibles of $257 and a monthly premium of $185 are fulfilled, there may be additional out-of-pocket costs due to coinsurance or copayments.
