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Patients often ask our prosthetists, "does insurance cover prosthetics?" Unfortunately, since insurance plans vary, we cannot give a definite answer. However, we are here to help make obtaining prosthetics as straightforward as possible with our custom prosthetics in Albuquerque and Las Cruces.
To that end, we will coordinate with insurance companies to ensure you receive the best prosthetic insurance. The following is some general information about the most common types of insurance and the type of prosthetic coverage they provide.
Comparing Prosthetic Device Coverage Across Health Plans
The cost of prosthetics will vary depending on your circumstances; the same goes for insurance coverage. In most cases, insurance plans will cover at least some of the prosthetic costs; however, you may not be enough to foot the total bill.
Therefore, it is essential to know the specifics of your insurance plan, the extent of its coverage, and your financial responsibility. Additionally, all types of insurance require you to have seen a doctor in the preceding six months.
Employer-Sponsored Insurance
Employers who provide coverage might pay a larger portion of the bill for prosthetic limbs. However, depending on your insurance plan, you must still meet your deductible and/or copay. The ACA requires small-group insurance plans to cover Essential Health Benefits, including prosthetics. Though large corporations often offer health insurance that covers prosthetics, the law does not require them to do so.
Marketplace Insurance
Marketplace insurance is a type of health insurance offered through the Health Insurance Marketplace, a government-run website that allows individuals, families, and small businesses to compare and purchase private health insurance plans.
When shopping for insurance for prosthetic limbs, comparing different plans and examining their coverage options is important. Marketplace insurance, in particular, must cover the Essential Benefits, which include prosthetic devices. However, the extent of coverage can vary greatly. For instance, some plans may only cover a prosthetic device if deemed medically necessary by a doctor.
Medicare Insurance
Does Medicare cover prosthetics? Yes, Medicare Part B (Medical Insurance) covers prosthetic devices when ordered by a Medicare-enrolled doctor or healthcare provider. After the Part B deductible is met, you are responsible for 20% of the Medicare-approved amount for external prosthetic devices.
Certain types of lower-limb prosthetics may require prior authorization from the state before Medicare will cover them. The amount owed for the prosthetic device varies depending on your other insurance, the doctor's charges, whether the doctor accepts the assignment, the type of facility, and where it is received.
Medicaid Health Coverage
Medicaid health coverage can cover prosthetic limbs. Typically, Medicaid covers prosthetic limbs as long as they are medically necessary and prescribed by a doctor. Check your local laws to see if Medicaid provides coverage for your prosthetic and the insurance claims you can make.
Based on your medical necessities, Medicaid may limit the size and type of prosthetic insurance it covers. To optimize your use of Medicaid, work closely with your prosthetic care provider to find an appropriate prosthesis.
Alternative Financial Aid for Prosthetic Devices
In addition to the classic options, additional prosthetic insurance coverage is available. If your health insurance does not fully cover the costs of the device or only covers a portion, you can receive assistance from several programs.
These include but are not limited to the following:
- U.S. Department of Veterans Affairs (VA)
- U.S. Department of Health & Human Services (HHS)
- Challenged Athletes Foundation (CAF)
- Limbs for Life Foundation
- American Amputee Coalition
If you are not a veteran or an ex-athlete, you can use a healthcare credit card like CareCredit to pay for a prosthesis. CareCredit is a useful option for financing various expenses, including medical equipment.
Prosthetic Medical Devices: What Medicare Covers
When you think of prosthetic devices, you may just think of body parts like arms or legs. However, this category of devices includes much more than that. Medicare prosthetic coverage includes a variety of devices, such as:
- Orthopedic braces for the arm, leg, and back
- Transhumeral prostheses
- Above-the-knee prosthetic devices
- Breast prostheses, including a surgical bra
- Prosthetic limbs and
- Therapeutic shoes for people with foot problems related to diabetes
If you have chosen Medicare Advantage (Part C) instead of original Medicare (Parts A and B), you may still be able to get an external prosthetic device covered as Durable Medical Equipment (DME) under Part B.
However, your insurance coverage for prosthetics may have additional rules or coverage limits, so check your plan details to determine exactly what's covered. Depending on your plan, you may need to get your device from certain in-network suppliers or facilities. If your device is surgically implanted and requires an inpatient hospital stay, it will be covered by Part A.
Qualifying for Prosthetic Device Insurance
Most patients know the difficulty of navigating health insurance when obtaining advanced prosthetics.
Anecdotes of those who have gone through the process often involve emotional appeals, out-of-pocket costs, and multiple trips to prosthetists nationwide before they are even considered for an electric prosthesis.
You must meet your insurance provider's criteria to qualify for prosthetic device insurance. Generally, this includes having a physical disability that requires using a prosthetic device. This may also include having a documented history of the disability and its effects on your life.
Your insurance provider may also require a doctor's prescription for the prosthetic device and documentation from a specialist in prosthetics or orthotics. Additionally, you may need to provide proof of your income and financial need.
To be eligible for prosthetic leg insurance coverage through most major insurance providers, a medical practitioner must justify that the device is "medically necessary."
Prosthetic Care Exclusions
The prosthetic devices covered by Medicare do not include:
- Cosmetic breast implants
- Dentures
- Eyeglasses or contact lenses
- Wigs, or head coverings for hair loss
Depending on your plan, some of these items may be covered by Medicare Advantage. Some health insurance for amputees includes extra coverage that original Medicare doesn’t, including dental, vision, and hearing care.
When signing up for Medicare Advantage, you can search for a plan that includes the devices you need or the ones you want your plan to cover.
Navigating Medicare Prosthetic Pricing
Giving an exact cost for prosthetic Medicare coverage is challenging because prosthetics can vary in complexity, cost, and usage. Additionally, insurance companies often have different coverage levels and premiums affecting Medicare benefits for amputees.
If you require a prosthetic device, Medicare will cover it in the same way as other durable medical equipment (DME) or implants provided that it is medically necessary, not just for cosmetic reasons, and is ordered by a physician who participates in the Medicare program and obtained from a supplier that participates in Medicare.
Here's How Medicare Coverage for Amputees Works
Costs with Part A
Does medicare cover amputation? Yes, Medicare covers all medically necessary amputations. Medicare Part A helps cover inpatient hospital care for an amputation, including the hospital stay, surgery, and other related care.
Medicare Part A covers prosthesis implantation as an inpatient procedure, with a deductible and no premium for the first 60 days of hospitalization. Post-surgery care for up to 20 days in a skilled nursing facility is also covered, with daily costs increasing after the 20-day mark. The facility and Medicare will cover any extra equipment you require during your stay, including wheelchairs, walkers, and orthotics.
Costs with Part B
Does medicare cover prosthetic legs? If you meet the criteria for coverage, Medicare will cover 80 percent of the cost of approved prosthetics, such as surgical bras and orthotics, that do not require surgery and can be used at home. You will be responsible for the remaining 20% and any cost exceeding the amount Medicare allows. In addition, you must pay your monthly Part B premium and meet your annual deductible before being granted coverage.
Costs with Part C
When selecting a Medicare Advantage plan, discussing the specifics of coverage and cost is important. All Medicare Advantage plans must provide at least the same coverage as original Medicare, but many plans offer additional coverage. The cost of a prosthetic device with a Medicare Advantage plan can vary greatly, so it is important to inquire about coverage and cost before signing up for the plan.
Costs with Medigap
Medigap plans are a private insurance option that can supplement original Medicare coverage, but not Medicare Advantage. These plans can help to reduce out-of-pocket costs associated with Medicare, such as Part A coinsurance, copayment, deductible, and hospital costs, as well as Part B coinsurance, copayment, deductible, and excess costs. The cost of Medigap plans varies by plan.
The Takeaway
At Primecare Orthotics & Prosthetics, we understand that every patient requires individualized prosthetic care. That's why our team will help you explore your insurance benefits and find a solution tailored to your coverage and needs.
Our clinic is committed to providing every patient with personalized prosthetic care. Our highly experienced prosthetists and staff will be available to meet with you and address any queries.
Don't hesitate to contact us for more prosthetic insurance information. We look forward to helping you navigate Medicare costs and assisting you, and being part of your journey to better health.
