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PUBLISHED:
March 3, 2023
Updated:
February 7, 2024
|
by
Eddie Zepeda

Are Prosthetics Covered by Insurance?

Prosthetics

Patients often ask our prosthetists, "Does insurance cover prosthetics?" Unfortunately, since insurance plans vary, we cannot give a definite answer. However, we’re 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 varies depending on your circumstances, and the same goes for insurance coverage. In most cases, insurance plans will cover at least some of the prosthetic costs; however, it may not be enough to foot the total bill.

Therefore, it’s 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

Employer-Sponsored Insurance

Employers who provide coverage might pay a larger portion of the bill for prosthetic limbs. Nevertheless, 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 doesn’t 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 are 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 it’s deemed medically necessary by a doctor.

Medicare Insurance

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’re 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 covers 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’s received.

Medicaid Health Coverage

Medicaid health coverage can cover prosthetic limbs. Typically, it’s done as long as they’re 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.

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:

If you’ve 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’ll be covered by Part A.

Qualifying for Prosthetic Device Insurance

Qualifying for Prosthetic Device Insurance

Most patients know the difficulty of navigating health insurance when getting advanced prosthetics.

Those who have gone through the process often experience emotional appeals, out-of-pocket costs, and multiple trips to prosthetists nationwide before they’re 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 needs to justify that the device is "medically necessary."

Prosthetic Care Exclusions

The prosthetic devices covered by Medicare don’t 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

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.

Medicare covers prosthetic devices under the same conditions as other durable medical equipment (DME) or implants as long as they meet the criteria of medical necessity, aren’t solely for cosmetic purposes, and are prescribed by a physician participating in the Medicare program. Moreover, these devices must be obtained from a supplier that is enrolled in the Medicare program.

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% of the cost of approved prosthetics such as surgical bras and orthotics that don’t 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 widely, so it’s 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 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.

Alternative Financial Aid for Prosthetic Devices

Alternative Financial Aid for Prosthetic Devices

Along with the classic options, additional prosthetic insurance coverage is available. If your health insurance doesn’t fully cover the costs of the device or only covers a portion, you can receive assistance from several programs that provide government help for amputees, financial assistance for prosthetic legs, and more.

Let's explore the options that offer help with above- and below-the-knee prosthetic legs in this critical time of need.

Government Programs and Grants

Government help for amputees, including under-insured amputees, is available through various programs and grants that are specifically tailored to provide financial assistance for prosthetic legs.

These initiatives may include federal, state, or local support, such as funding for prosthetics, vocational rehabilitation programs, and Labor National Contact Center assistance. Applicants can consult with local agencies to understand eligibility and application processes, including whether a private health insurance plan is necessary.

Organization Name Contact Information Description
Medicare 800/633-4227; medicare.gov Provides coverage for orthotics, artificial limbs, and eyes. There are specific links and pages detailing the types of devices covered, how the coverage works, and associated costs. Offers different options based on Original Medicare and other Medicare types. Resources are available such as the Amputee Coalition's Fact Sheet: Medicare for People with Limb Loss.
Medicaid 800/633-4227; medicaid.gov Provides eligibility for Medicaid and CHIP coverage, with particular emphasis on prosthetics and rehabilitative services as Essential Health Benefits (EHB) under the Affordable Care Act.
Veterans Administration 1-877-222-8387; va.gov Responsible for national policies and programs for medical rehabilitation, prosthetic, and sensory aid services for veterans with disabilities. Offers specific eligibility requirements, and further details can be found at prosthetics.va.gov.
U.S. Department of Health & Human Services (HHS) 1-877-696-6775;
hhs.gov
The U.S. Department of Health & Human Services, through the Centers for Medicare & Medicaid Services (CMS), provides coverage for prosthetic and orthotic devices for amputees under certain conditions.
TRICARE 866/487-2365 Department of Defense's healthcare program covering prosthetics and related devices/supplies for active-duty and retired uniformed service members and their families. Coverage details and specific rules can be found on the TRICARE website, including options and exclusions.
Vocational Rehabilitation 866/487-2365 U.S. Department of Labor National Contact Center. Provides assistance to people with disabilities, including limb loss, in obtaining and keeping employment or in using prostheses or other adaptive devices. Programs vary from state to state. Contact your state’s Department of Health and Human Services office for specific programs.
Private Insurance 800/318-2596; healthcare.gov Coverage provided under the Affordable Care Act ("Obamacare") with provisions relating to Essential Health Benefits (EHBs) including rehabilitative services and devices. Open Enrollment details and specific state-related information can be found on the website, along with the Amputee Coalition's Fact Sheet.
Medical Discount Programs Information available at consumer.ftc.gov These programs negotiate with Preferred Provider Organization (PPO) providers for discounts on medical goods and services, including Durable Medical Equipment (DME). Prosthetic care is usually not specifically mentioned, but further details on these programs can be found in the provided link.

Non-Profit Organizations

Many non-profit organizations dedicate themselves to helping those in need of prosthetic devices, especially those without health insurance coverage or essential health benefits. Working with local communities, these organizations offer financial support and help with prosthetic legs to bridge the gap for those who may not qualify for government assistance or lack adequate health insurance.

Organization Name Contact Information Description
Ability Found 2324 S Constitution Blvd, West Valley City, UT 84119; 877/231-4567; abilityfound.org Provides assistance in obtaining various types of medical equipment, but not prosthetics or orthotics. Items include shower chairs, hospital beds, manual and power wheelchairs, and more. A small contribution for shipping costs may be required.
Amputee Blade Runners 356 24th Avenue North, Suite 300, Nashville, TN 37203; 615/752-1233; amputeebladerunners.com Helps provide free running prosthetics for amputees, allowing them to keep an active lifestyle.
Challenged Athletes Foundation (CAF) 9591 Waples St., San Diego, CA 92121; 858/866-0959; challengedathletes.org Offers grants to athletes with physical disabilities recognized within the International Paralympic Committee classifications. Provides funding for coaching fees, competition expenses, or equipment.
Chive Charities chivecharities.org/recipient Focuses on rare medical diseases and serves first responders and veterans with medical needs.
Fighting Back Scholarship Program 610/688-8868; fightingbacksp.org Provides financial scholarships for individualized exercise rehabilitation to those who have suffered a life-changing illness or injury.
Global Reach Bionics Fayetteville, AR; globalreachbionics.org Seeks to provide free prosthetics to disadvantaged amputees.
Heather Abbott Foundation 181 Belleview Ave #407, Newport, RI 02840; heatherabbottfoundation.org Committed to helping individuals who have lost limbs get specialized prosthetic devices.
Help Hope Live 2 Radnor Corporate Center, Suite 100, 100 Matsonford Road, Radnor, PA 19087; 800/642-8399; helphopelive.org Helps clients raise funds to cover the costs of uncovered medical expenses including medications, durable medical equipment, physical therapy, innovative treatments, and more.
Life Nets lifenets.org/wheelchair The Wheelchair Project takes donated wheelchairs and gives them to individuals in need.
Limbs for Life Foundation 9604 N May Ave, Oklahoma City, OK 73120; 888/235-5462; limbsforlife.org Assists lower-limb amputees in the U.S. with no other means to pay for prosthetic care.
Limb Preservation Foundation 1721 E 19th Ave, Suite 106, Denver, CO 80218; 303/429-0688; limbpreservation.org Committed to the prevention and treatment of limb-threatening conditions due to cancer, trauma, or infection. Serves individuals residing in the Rocky Mountain Region.
Mending Limbs Organization 214 Watson View Dr., Franklin, TN 37067; 615/390-3450; mendinglimbs.org Provides assistance with funding for prosthetic costs not adequately covered by insurance.
Move For Jenn P.O. Box 77578, Charlotte, NC 28271; 704/710-6299; moveforjenn.org Offers grants to sarcoma researchers and those who have lost a limb due to sarcoma or other affiliated diseases, to help afford or obtain an active-wear prosthetic.
National Military Family Association militaryfamily.org/info-resources/efmp-special-needs.html Offers support to military families to help ensure access to services for medical, educational, or psychosocial needs.
ROMP USAP P.O. Box 100915, Denver, CO 80250; rompglobal.org/usap Serves people with amputation who don’t have access to prosthetic care due to immigration status, lack of insurance, or financial hardship.
Steps of Faith Foundation P.O. Box 15064, Lenexa, KS 66285; 615-426-6034; stepsoffaithfoundation.org Helps uninsured and under-insured amputees get prosthetic limbs to restore their livelihood.
Steve Chamberlin’s 50 Legs 50legs.org Provides amputees with necessary care and prosthetics that they couldn’t otherwise afford.
The Wheelchair Recycler 508/460-6328; wheelchairrecycler.org Refurbishes donated power wheelchairs and reissues them to consumers at little to no cost.
The Amputee Coalition Albuquerque, NM Office; 888/267-5669; amputee-coalition.org Provides education, outreach, support, and advocacy for people affected by limb loss or limb difference in the Albuquerque area. Programs include peer support, awareness campaigns, educational events, and assistance in accessing proper prosthetic care. The organization's mission emphasizes empowerment, support, and connection within the limb loss community.

Services for Children and Young Adults

Numerous organizations are dedicated to providing financial assistance to children and young adults who require pediatric prosthetic devices. While children may be eligible for assistance through general programs mentioned earlier, we've outlined groups specifically focused on serving the unique needs of children and, in some cases, young adults.

Organization Name Contact Information Description
Cancer Survivors Fund cancersurvivorsfund.org Assists with the cost of prostheses for children and young adults with cancer-related needs.
First Hand Foundation 816/201-1569, [email protected] Funds individual children for clinical necessities, medical equipment, and travel related to care.
Jordan Thomas Foundation 423/622-9006 Assists children affected by limb loss with prostheses up to age 18, with a one-time program for ages 18-24.
Lost Limbs Foundation lostlimbsfoundation.org Offers financial assistance to children with amputations for medical and prosthetic assistance.
Variety The Children’s Charity 323/954-0820, [email protected] Grants mobility equipment such as wheelchairs, walkers, and prosthetics.
Wheel to Walk Foundation wheeltowalk.com Helps children under 20 obtain medical equipment not covered by insurance; limited to certain states.
State Children’s Insurance Program (CHIP) chipmedicaid.org Provides low-cost health coverage for children in families that don't qualify for Medicaid.
Shriners Hospital 800/237-5055 Offers free orthopedic care to children under 18, including prosthetics.
St. Jude Children’s Research Hospital 901/595-3300 Provides prosthetic care in conjunction with treatment of catastrophic illnesses like osteosarcoma.
Blue Cross Blue Shield (BCBS) bcbs.com Offers free or low-cost coverage to children through “Caring for Children Foundations,” varying by location.

If you’re 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.

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 being part of your journey to better health.

Request an Evaluation

If you have questions or you are ready to talk about prosthetic options, feel free to schedule a consultation at our clinic.

A grandfather with a prosthesis walks with his grandchildren.