Does Medicaid Cover Incontinence Supplies

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Medicaid is a public health insurance program run by states and territories that covers adults and children with low incomes or disabilities. The program is jointly funded by the U.S. government and all states, Washington, D.C., and five U.S. territories:

• American Samoa

• Guam

• NortheMariana Islands

• Puerto Rico

• U.S. Virgin Islands

Medicaid and the Children's Health Insurance Program (CHIP) covered more than 83 million people in the U.S. as of February 2024. This comprehensive insurance covers most medical services and supplies. Most Medicaid programs offer some coverage for incontinence products, but specifics vary by state and territory.

What is incontinence?

Urinary incontinence is involuntary leakage from the bladder. It can happen to anyone at any age but is most common in women older than age 50 and seniors.

Urinary incontinence can result from conditions such as cerebral palsy or dementia, including Alzheimer's disease. It can range from occasional leaks to the inability to hold urine.

An estimated 13 million people in the U.S. have urinary incontinence - which includes half of people in nursing homes and more than half of homebound older people, according to caregivers. Incontinence also includes the inability to control the bowels, which is known as fecal incontinence.

Types of incontinence

There are five types of urinary incontinence:

• Stress incontinence: This involves involuntary leakage of small amounts of urine due to bladder pressure from activities such as coughing, sneezing, exercise, or pregnancy. Fecal stress incontinence includes occasional fecal smears.

• Urge incontinence: A strong urge to urinate cannot be contained until reaching the bathroom. This may be caused by bladder spasms known as overactive bladder, irritation, or neurologic issues.

• Mixed incontinence: This involves involuntary leakage of urine caused by a combination of stress and urge incontinence.

• Overflow incontinence: Your bladder doesn't empty completely or you lack the urge to urinate, so you have urine leaks. This can result from multiple sclerosis or neurologic impairments such as spinal cord injuries. The same lack of awareness of needing to have a bowel movement can cause fecal incontinence.

• Functional incontinence: Your bladder leaks because of physical or environmental barriers. This may include restricted mobility, arthritis, injury, or disability.

Are incontinence supplies covered by Medicaid?

Yes, most Medicaid programs offer some type of coverage for medically necessary incontinence supplies for children and adolescents as well as adults. However, coverage requirements and program rules vary because states and territories are not required to offer this benefit.

Medicaid programs are required to cover diapers and other incontinence products for eligible enrollees older than 3 or 4 and younger than age 21 through the Early and Periodic Screening, Diagnostic, and Treatment benefit. Qualifying children and adolescents typically have developmental delays and/or medical conditions such as cerebral palsy.

Most Medicaid programs limit the number of products you can order every month and have a monthly dollar amount you can't exceed without authorization.

"Most states are going to have a limit based on what they often refer to as units allowed," said Janet Firestone, national Medicaid account executive for Tranquility, a manufacturer of super-absorbent incontinence products available for delivery by mail and in medical supply stores. "[States and territories] look at an average month and then estimate what a person might use on a daily basis."

Figuring out your state or territory's current policies may not be as easy as a simple internet search. Covered supplies and allowed quantities can vary based on waivers or demonstration programs that include items not listed as covered in primary documents.

Legal action can also prompt policy updates. A settlement reached in 2023 is expected to lead to the Florida Medicaid program covering incontinence supplies for people 21 and older with disabilities that cause bladder and bowel incontinence.

Typically, mail-order healthcare supply companies that serve your state or territory have representatives who can help you determine if and how incontinence products are covered for you by your Medicaid program, Firestone added.

Which incontinence products are covered by Medicaid?

Your Medicaid plan may cover some or all of the following products:

• Barrier creams

• Bladder control pads and guards

• Booster pads, which fit inside protective underwear

• Diapers, which are called disposable briefs when they are for adults

• Disposable or protective underwear, also known as pull-ups or pull-ons

• Disposable wipes

• Underpads, known as chux, to protect areas such as furniture, mattresses, and car seats from leaks

There are many types and brands of incontinence products. These products absorb or contain urine or feces, can keep your skin dry, and may prevent skin rashes and sores. It's best to work with an incontinence product supplier to find the products that best fit your situation.

When evaluating incontinence products, consider factors that are important to you, which could include:

• Comfort

• Cost

• Ease of use

• Odor control

Trying products

Don't be afraid to try different products and brands until you find one that is comfortable and meets your needs. Most companies will send you samples by mail, but beware of two issues when making these requests:

• Paying shipping fees

• Signing up for unwanted subscriptions

Also, don't limit your search to drugstore, grocery store, or big-box retail options. Brands available by mail order and at medical supply stores may be more absorbent, higher-performing, or better-fitting options.

How to get incontinence supplies through Medicaid

Medicaid covers incontinence supplies for children and adolescents older than 3 or 4 with complex healthcare needs, and may cover products for adults who meet certain criteria - such as those who have disabilities.

To qualify for incontinence supplies coverage through Medicaid, you typically need a prescription from a physician or healthcare professional with a qualifying diagnosis. You may also need prior authorization.

Your documentation should typically outline your condition, why you need incontinence supplies, and the estimated number of incontinence care products you need per day.

Ask your healthcare professional if they can help you find the best way to get incontinence supplies covered by Medicaid. They may refer you to a care coordinator who can help you navigate the process. You can also contact medical supply companies or incontinence product manufacturers for guidance.

"One of the things I tell a lot of people that I work with is: 'Don't give up, because sometimes that first part is the longest part,'" Firestone said. "We just try to encourage folks to keep staying the course and getting the required documentation. And once it's set up, it's usually a monthly supply delivered to them and it helps the family out."

Incontinence supply coverage by state or territory

As mentioned, Medicaid programs are required to cover incontinence products for children and adolescents under 21 who qualify. Most states also cover incontinence products for certain adults 21 and older.

Over her career of more than two decades, Firestone said she has assisted people in obtaining Medicaid coverage for incontinence supplies in all 50 states - though the benefit may only extend to children and eligibility requirements can change year to year.

This list indicates which states cover some incontinence supplies for certain adults.

Incontinence supplies: Medicaid coverage by state or territory*

*Information is current at the time of publication. Coverage can vary because of waivers or demonstration programs as well as your specific Medicaid or Medicaid-managed care plan. If you live in one of the U.S. territories, contact your Medicaid program for more information.

How to get free or low-cost incontinence products

Your Medicaid program may not cover the incontinence products you need - or you may require supplies that exceed the allowed items or maximum dollar amount. If you need access to free or low-cost incontinence products, check with diaper banks, food banks, and other community organizations that give away free children's diapers. They may also stock adult diapers and incontinence supplies.

Programs that cover products or provide savings

Veterans may qualify for a special benefit through the U.S. Department of Veterans Affairs that covers incontinence products. Active-duty military members and their families may be eligible for incontinence supplies through Tricare ECHO (Extended Care Health Option).

In addition, people enrolled in the Program of All-Inclusive Care for the Elderly known as PACE can get their incontinence supplies covered through PACE.

Some states, including Florida, don't charge sales tax on incontinence products. According to the National Diaper Bank Network, 26 states charged sales tax on diapers and incontinence supplies as of July 20, 2023 - but 24 states and the District of Columbia did not (or don't have a sales tax).

Does Medicare cover incontinence supplies?

While original Medicare doesn't cover incontinence supplies, some Medicare Advantage plans may. If you are diagnosed with permanent urinary incontinence or permanent urinary retention, Medicare Part B may cover urological supplies such as urinary catheters and external urinary collection devices. Coverage for these devices will also include some associated supplies.

Frequently asked questions

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GoodRx Holdings Inc. published this content on 26 June 2024 and is solely responsible for the information contained therein. Distributed by Public, unedited and unaltered, on 27 June 2024 18:23:27 UTC.