Ostomy Supply Reimbursement

Living with an ostomy in Canada impacts your financial well-being. Ostomy supplies can be costly, and individual needs may drive the cost up. There are various ways to obtain reimbursement; however, the type and availability vary greatly depending on the province in which you reside. While some provinces offer public funding, some provide little to no support, and many programs do not cover temporary ostomies.

Ostomy Canada can assure Canadians that we are actively involved in advocacy with the government to provide these services; unfortunately, we cannot offer financial assistance. (Can John give a statement from the advocacy team and include any partnerships involved in the matter? The information should be linked to another section of the website examining this issue).

Below we will explore how you may obtain reimbursement for your ostomy supplies. Please note that we are providing a high-level overview, so we encourage you to review this topic in depth through the links provided for each program.

Glossary of Terms

Premium

A premium is the amount of money charged by your insurance company for the plan you've chosen. It is usually paid monthly but can be billed in several ways. You must pay your premium to keep your coverage active, regardless of whether you use it or not.

Premium

Here's an example...

You’ve checked out rates, and the health plan you prefer costs $175 per month, which is your premium. To purchase ostomy supplies, you need to keep your benefits active by paying your premium on time every month.

Deductible

A deductible is a set amount you have to pay every year toward the total cost of your medical bills, including ostomy supplies before your insurance provider starts paying. It varies by plan, and some programs don't have a deductible.

Deductible

Here's an example...

Your plan has a $500 deductible. That means you pay for your ostomy supplies up to $500 for the year. Then, your insurance coverage kicks in. At the beginning of each year, you’ll have to meet the deductible again.

Coinsurance/
Cost-Share

Coinsurance or Cost-Sharing is the percentage of the medical bill you share with your insurance company after you've paid your deductible. Unless you have a policy with 100% coverage for everything, you have to pay a coinsurance amount.

Coinsurance/
Cost-Share

Here's an example...

You have a "75/25” plan. That means your insurance company pays for 75% of your ostomy supply costs after you've met your deductible. You pay 25%. Coinsurance is different and separate from any co-payment.

Copayment (or "copay")

Your co-payment, or copay, is the flat fee you pay every time you go to the doctor or fill a prescription. It's usually a relatively small dollar amount. Copays do not count toward your deductible.

Copayment (or "copay")

Here's an example...

Let’s say your plan has a $25 co-payment for ostomy supply orders. That means you have to pay $25 each time you place an order. Co-payments are different than coinsurance.

Third-Party Health Insurance Benefits

Third-party health insurance includes public programs like NIHB, Veteran’s Affairs, private health insurance programs like Blue Cross or Green Shield, and employer benefits like Sunlife. If you have third-party coverage, you may not be eligible in some provinces for their ostomy supply reimbursement program.

Third-Party Health Insurance Benefits

Here's an example...

You ordered ostomy supplies costing $200, and your insurance benefits through your employer cover 80% of supplies. There is a remaining balance of $40, which you must pay out of pocket. You later claim this on your income taxes as a medical expense.

Payor of Last Resort

Payer of last resort means that a benefits program only pays after all other third-party programs have been pursued for payment.

Payer of last resort

Here's an example...

Your private insurance covered 75% of your ostomy supply order. You receive the reimbursement and then submit proof of that, along with your original receipt and send it to your provincial program for reimbursement.

Authorization

A physician, an NSWOC, or approved medical professional must assess your ostomy and authorize you for provincial ostomy coverage.

Authorization

While in the hospital, an NSWOC nurse assesses your ostomy and approves your application to receive provincial health benefits for your ostomy supplies.
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