Does Medicare Cover Prosthetics? Understanding Your Benefits

Yes, Medicare covers prosthetic devices.

However it's not as simple as being on Medicare and ordering any device you want. There are certain criteria that must be met first. If you don't follow the correct procedure or use a Medicare approved supplier you could be responsible for the full amount of your prosthetic device, which could cost you 1000s of dollars!

We will cover what prosthetic devices are covered by Medicare and how you can follow the correct procedures to avoid any additional costs associated with these devices.

What are Prosthetics?

Prosthetics are either artificial limbs or devices that replace a missing body part, which may include limbs, eyes, or other components that are essential to perform daily functions. These devices are vital for over 2 million U.S. citizens, as they help individuals regain mobility and maintain an independent, fulfilling life.

These devices are classified into two groups.

External prosthetic devices

External prosthetic devices include:

• Prosthetic legs, arms, hands and feet
• therapeutic shoes for people with foot problems related to diabetes
• Breast prostheses following a mastectomy, which can encompass implants (i.e. a surgical bra).
• Supplies and ostomy bags
• Contact Lenses or glasses associated with cataracts surgery

Internal Prosthetic devices

• Prosthetics Eyes
• Surgically implanted prosthetic devices

What Does Medicare Generally Cover?

Medicare is divided into different parts: Part A, B, C (Medicare Advantage), and D.

When you hear the term Original Medicare. This is normally referring to Medicare Part A and B.

Part A covers inpatient hospital care and surgeries, Part B covers outpatient medical services, Part C is an alternative called Medicare Advantage offered by private companies, and Part D covers prescription drugs.

Will Medicare Part A Cover Prosthetic Devices?

Medicare will cover prosthetics provided that the device is deemed medically necessary (not just cosmetic) and the surgery is performed as an in-patient hospital procedure. With part A you'll be responsible for paying the deductible ($1,600 as of 2023)and depending on your length of stay at the hospital or a skilled nursing facility potentially more in co-insurance.

Fee Schedule Per Medicare.gov

You pay this for each benefit period:

• Days 1 - 20: $0 coinsurance
• Days 21 - 100: Up to $200 coinsurance per day
• Days 101 and beyond: All costs

There's a 100-day limit of Part A SNF coverage in each benefit period.

Does Medicare Part B Include Prosthetic Devices?

For prosthetics, Original Medicare Part B is usually the section that provides coverage as it falls under Durable Medical Equipment (DME). However, there are certain conditions that must be met.

For Medicare to cover your prosthetic, it's imperative that the prosthetic is deemed medically necessary. This entails that the prosthetic is required to replace a missing body part or to restore its functionality. If the medical necessity is established, Original Medicare Part B will cover 80% of the cost of the device.

As with Part A coverage it is crucial to remember a couple of vital conditions. Firstly, the physician prescribing the prosthetic must accept the Medicare program. Secondly, the prosthetic must be purchased from a supplier that is approved by Medicare. Failure to adhere to these stipulations might result in you having to cover the entire cost of the prosthetic.

Part B Surgical Procedures

If a surgical procedure, such as cataract surgery or cochlear implants, is performed in an outpatient care facility, remember that your coverage and costs will be considered as Medicare Part B benefits with the associated deductibles and copays (20% of the total Medicare-approved amount of the device).

What Are the Costs Associated with Medicare Coverage for a Prosthetic Device?

Medicare Part B usually covers 80% of the approved amount for the prosthetic device after you have met the Part B deductible. You are responsible for the remaining 20%. The actual costs of prosthetics can vary significantly based on the type and complexity of the device.

It is critical to ensure that both the prescribing doctor and the supplier are Medicare approved to avoid unexpected out-of-pocket costs.

Can Individuals with Limb Loss or Other Disabilities Qualify for Medicare?

Medicare primarily serves as insurance for individuals aged 65 or older, particularly those who have contributed to Medicare through taxes during their working years. Nonetheless, there are certain exceptions that allow individuals younger than 65 to qualify for Medicare.

If you are under 65, you might be eligible for Medicare if you meet one of the following criteria:

• You are diagnosed with end-stage renal disease.
• You are diagnosed with amyotrophic lateral sclerosis (ALS).
• A certified medical professional verifies that you have a disability that prevents you from engaging in any form of substantial employment.

It is important to understand what qualifies as a disability in the context of Medicare. To be deemed disabled, an individual must be incapable of engaging in "substantial gainful activity" for a minimum period of 12 months. Notably, about 16% of Medicare beneficiaries qualify on the grounds of disability.

Now, let’s address limb loss specifically. The mere fact of having experienced limb loss doesn’t automatically classify one as disabled. However, considered medically, if limb loss or any other injury or chronic medical condition impairs your ability to work, a doctor may certify you as disabled. Typically, eligibility for Medicare requires that you receive Social Security disability benefits for at least 24 months.

If you have experienced limb loss and it has adversely affected your ability to work, it’s essential to consult your doctor for an assessment. If your doctor certifies that you meet the criteria for disability, you may become eligible for Medicare after a specific period of receiving Social Security disability benefits. Being informed and proactive about your health and Medicare eligibility is crucial in ensuring that you receive the support and care that you need.

How Does a Medicare Advantage Plan (Part C) Provide Coverage?

Medicare Advantage (Part C) is an alternative to Original Medicare that is required to offer at least the same level of coverage as Medicare Part A and B. Some Medicare Advantage plans may offer additional benefits or lower out-of-pocket costs.

These plans often have a network of doctors and suppliers, and it's essential to use those within the network to receive the full benefits of the plan. Each plan provides a list of physicians (primary care physicians and specialists in your area that you'll be able to consult) that are in the plan's network.

It's important to note some plans may require you to first visit a primary care physician in the coverage network to receive approval for a surgical procedure.

What Steps Should Be Taken for Medicare Coverage?

To ensure that Medicare covers your prosthetics, it is important to follow these steps:

1. Consult with your doctor and confirm that they accept Medicare assignment for your visit.
2. Ensure that the prosthetic device is prescribed for a medically necessary reason.
3. Choose a supplier that is enrolled in the Medicare-approved supplier search list.
4. Stay informed about any changes in Medicare benefits or costs. Check with your insurance carrier's plan before any major surgeries or prosthetic devices are ordered.

Important Takeaway

Prosthetics play an essential role in enhancing the quality of life for individuals with missing limbs or body parts. Understanding Medicare’s coverage for prosthetics is crucial in managing your healthcare costs effectively and avoiding any unnecessary financial burdens.

Find The Coverage That is Right for You

If you are considering your options and looking for a plan that suits your specific needs, we encourage you to connect with an EASY Insurance Plans agent. Our experienced agents can provide you with a FREE consultation and guidance necessary to find a Medicare plan with the benefits best suited to your needs.