Artificial devices called prostheses can replace a missing part of a person’s body, such as an arm or a leg. Medicare tends to cover prosthetic devices and supplies.
In addition, prostheses may include cochlear implants, contact lenses after surgery, and breast prostheses after a mastectomy.
Medicare generally provides coverage for prosthetic devices and supplies, though there may be some restrictions and some costs.
In this article, learn more about prosthetic devices and the coverage that Medicare provides.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
A prosthetic device can replace a missing body part. These devices include prosthetic limbs, cochlear or breast implants, and prosthetic eyes.
Alongside these devices, there may be other related supplies, such as:
- ostomy bags and supplies
- urinary catheters and supplies
- enteral nutrition
- certain eyeglasses and contact lenses
- mastectomy bras
Medicare generally provides coverage for prosthetic devices and supplies, though there may be some restrictions. The list below provides more details on these.
- The prosthesis — whether they are implants, devices, or items — must be for use in a person’s home or a long-term care facility.
- The person must obtain the prosthetic items, implants, or devices from a Medicare-approved supplier.
- In some states, there may be a requirement for prior Medicare authorization for some types of lower limb prosthetics.
Original Medicare (Part A and Part B) may cover surgically implanted prosthetic devices, depending on whether the surgery takes place in an inpatient or outpatient setting.
If a prosthetic device is destroyed, lost, irreparably damaged, or rendered unusable due to a declared emergency, Medicare may pay for a replacement. However, a Medicare-enrolled supplier must provide the replacement prosthetic.
Although Medicare may cover most of the costs, a person may have to pay coinsurance, copays, or deductibles.
For external prosthetic devices, Medicare covers 80% of the costs, with a person paying 20% of the Medicare-approved amount plus the Medicare Part B deductible of $203. The person getting the device or supplies can submit the claim, or their doctor can do this.
A person can check with their doctor for the exact cost of the prosthesis, as the amount may vary depending on several factors. These include doctor fees, any other insurance a person may have, and whether or not the supplier accepts the assignment.
Medicare Advantage plans cover the same medically necessary items and services as original Medicare (Part A and Part B). The costs may vary depending on the Medicare Advantage plan the person chooses.
A person can check with their plan provider about coverage for a prescribed prosthetic device. If the Medicare Advantage plan will not cover it, the person can appeal and request an independent review of the coverage.
If a person is currently using a prosthetic device, supply, or item and plans to join a Medicare Advantage plan, they can check with their plan provider and doctor to ensure coverage for any prescribed prosthetics and related services.
Medicare Part D
Private health insurance providers offer Medicare Part D plans, which help meet the cost of outpatient prescription drugs.
Many Medicare Advantage plans also offer prescription coverage. Alternatively, a person who is eligible for original Medicare (Part A and Part B) can enroll in a separate Part D plan.
Before choosing a prescription drug plan, a person should check its formulary, which is a list of covered drugs, for their prescribed drugs. They should also check costs for deductibles, monthly premiums, copays, and coinsurance.
There are several funding sources, though each one generally has specific requirements.
Some nonprofit organizations provide grants that may help a person get a prosthetic device.
The Heather Abbott Foundation support individuals who have lost limbs due to traumatic circumstances. Specifically, they help people get specialized prosthetic devices. To apply for a Heather Abbott Foundation grant, a person can complete this online form.
Alternatively, the Mending Limbs Organization are a nonprofit organization who offer help with funding for prosthetic costs that insurance may not cover. A person can apply for funding using this online form.
Children and young adult services
The Jordan Thomas Foundation are a nonprofit foundation who provide prostheses to children up to the age of 18 years affected by limb loss.
They also serve as advocates and as a support system for children and their parents. They offer a one-time assistance program for young adults aged 18–24 years.
Medicaid and Medigap
Medicaid may help with costs related to prosthetic devices. Medicaid is a health program that states administer and operate with the support of the federal government.
Each state program can vary depending on the goals of each state. For more information, a person can contact their state agency.
Medigap may also help with costs related to prosthetic devices. Medigap is medical insurance that private insurance companies offer, and it intends to fill in “gaps” in original Medicare (Part A and Part B) coverage.
In most cases, a person must be enrolled in Medicare Part A and Part B before they can get a Medigap policy.
Prosthetic devices can replace missing body parts. Medicare may cover prosthetic devices when a doctor prescribes them for use in the home or a long-term care facility.
A person must obtain the prosthetic device from a Medicare-enrolled supplier in order to receive coverage.
Costs may include 20% of the Medicare-approved amount after the person has paid the Part B deductible. There are several nonprofit, state, or federally funded funding sources that may help with these costs.