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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’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
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
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:
- Orthopedic braces for the arm, leg, and back
- Transhumeral prostheses
- Above-the-knee prosthetic devices
- Breast prostheses, including a surgical bra
- Prosthetic limbs
- Therapeutic shoes for people with foot problems related to diabetes
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
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
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
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.
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.
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.
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.
