The Supplier Must Be Enrolled: Compare Incontinence Supply Sellers on Payer Rules, Order Terms, and Refills Before You Buy

A box of supplies looks like a simple store purchase until you find out who else is supposed to pay for it. Before you compare sellers, split the order into three parts: what the family buys outright, what a payer might cover, and what a seller might bill to a payer for you. Each part has its own questions, and a seller's brochure answers only some of them.

Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.

Who pays, first

Start with the payer, not the price. Original Medicare covers a narrow set of these items under its rules for equipment and supplies. It pays only when a doctor orders the item for a qualifying reason and a supplier enrolled in Medicare bills for it (see the Medicare.gov pages on durable medical equipment and supplies). Most ordinary products bought at a store are paid by the family. If a Medicare Advantage plan is involved, the plan has its own list of covered products and its own network of sellers. If Medicaid is involved, check the covered-supplies list published by the Missouri Department of Social Services for MO HealthNet, Missouri's Medicaid program, rather than relying on a seller's summary of it. Ask each payer, in writing, which products it covers and which sellers it contracts with.

Check the enrollment before the cart

An enrolled supplier is a seller that has signed the payer's enrollment paperwork. Ask each seller for its enrollment status with Medicare and with any plan or Medicaid program you expect to use, along with the identifying number it holds with that payer. Then look up that number in the payer's directory yourself. A seller who says it accepts Medicare, without showing where that appears in the payer's records, is giving you a sales line, not a contract term. If a seller will not show its enrollment, move on to one that will.

Compare the order terms

Put the sellers side by side on the same lines. Ask for the exact product name, the size, and the quantity per shipment. Ask whether the seller will substitute a different product, and whether a substitution changes the price or the payer's coverage. Ask who bills the payer, who receives the statement, and whether you will see an explanation of benefits before you are asked to pay any balance. If a seller will not put the answers in writing, treat that as the answer.

Refills, changes, and cancellation

Recurring shipments are where the cost drifts. Read the auto-renew line, the minimum order, the shipping charge, the return policy, and the number to call to change an order. Ask what happens when the doctor changes the order, who files the new paperwork, and whether you can stop a shipment without a fee. A seller that makes the change process hard to find is telling you how the account will run.

What the family decides and what it hands off

The family decides what gets ordered and when, and it keeps the copy of every order. A non-medical helper can carry a delivery to the door or make a phone call to a seller as an errand, but the choice of product and quantity belongs to the family and the doctor. The doctor decides what is needed and in what amount. A lawyer takes over if a payer denies a claim and an appeal is needed. For questions about plan coverage, the free state health insurance counseling program, Missouri SHIP, can walk you through the plan's own documents. Our Local Help With Paying for Care page lists where to call, and the Sources page lists the public pages each claim here comes from.