Advocacy in action: Increasing access to medical supplies for Wisconsin residents with Medicaid

The Coloplast Market Access team is continuously working to protect and improve access for people with intimate health care needs. The team identified that ostomates with Wisconsin Medicaid were limited in their ability to access suitable quantities of extended wear ostomy products. Unfortunately, there is a misconception that extended wear products allow all users to achieve longer wear times than standard wear products. And, as a result, health plans may set quantity limits that are unsustainably low. While some ostomates may achieve longer wear times with extended wear products, many ostomates require similar quantities as standard wear ostomy products. CMS defines extended wear as “a pectin-based barrier with special additives which achieve a stronger adhesive seal, resist breakdown by urine or bowel effluent, permit longer wear times between changes, and normal wear times for those who cannot achieve them with standard barriers. There are distinct codes for extended wear compared to standard wear barriers.” Every ostomate is unique in body type, stoma and effluent and will require a solution specific to their needs.

Prior to Dec. 1st, 2022, the Wisconsin Medicaid program allowed quantities of 6 and 10 per month for extended wear ostomy products. Through a successful collaboration of efforts with the Midwest Association for Medical Equipment Services & Supplies (MAMES), Wisconsin Insurance Committee and support from the United Ostomy Association of America (UOAA), Wisconsin Medicaid has increased the allowed quantity for extended wear products to 20 per month. UOAA President Cheryl Ory commented: "When the unique needs of people living with an ostomy are recognized, it is a win for all. Thank you to everyone on the coalition team who helped educate and advocate in Wisconsin, these improvements will make a real difference in people's lives."  

Simultaneously, the Wisconsin Committee worked to add appropriate coverage and reimbursement for the Peristeen Plus Transanal Irrigation (TAI) system, HCPCS A4459 and A4453. TAI is an effective bowel management technique for people with Neurogenic Bowel Dysfunction (NBD) suffering from constipation or fecal incontinence. TAI is covered by most state Medicaid plans, as well as numerous commercial and managed care products. The Coloplast Market Access team, in collaboration with the MAMES Wisconsin Insurance committee, worked with the Wisconsin Medicaid policy team to add TAI coverage and reimbursement and were successful in adding HCPCS A4459 and A4453 as covered codes effective May 1, 2022.  

As we have entered 2023, the Coloplast Market Access team wants to express their gratitude for the support of our industry partners in protecting and expanding access for individuals with intimate health care needs. There is still work to be done and the team continues to address challenges in other states. If you are aware of access issues for people living with stomas, or bowel/bladder dysfunction and/or would like to assist with advocacy efforts, please contact the Coloplast Market Access Team at USReimbursement@coloplast.com.  

Jason is the senior manager of payor relations for Coloplast and is a 25-year veteran of the HME industry with extensive experience in the reimbursement and payor relations arenas. Jason has a passion for strategic leadership and advocacy work and currently serves as chair of the AAHomecare Payer Relations Council, as well as a board member for multiple entities, including AAHomecare, HOMES Association, MA Board of Respiratory Care and Northern Essex College Respiratory Care Advisory Board.