Medicare covers a variety of prosthetic devices if they’re necessary to replace a body part or function. Also, your doctor must order them.
Depending on your other insurance, you may only pay a portion of the cost. Beneficiaries must meet terms before Medicare covers the prosthetic.
Devices and supplies come in all shapes and sizes. Your healthcare provider may prescribe any of these to you, depending on your medical condition. The option to use prosthetic devices can be vital for those with specific medical needs.
The way prosthetic devices are advancing is no exception. New options give patients the chance to customize.
Examples of devices range from artificial teeth, eyes, facial bones, the palate, artificial hip, knee and other joints, legs, arms, and more.
Below we’ll discuss WHICH devices have coverage and HOW Medicare covers them.
Does Medicare Cover Prosthetics
If your prosthetic is implanted surgically, coverage depends on the procedure location. For example, inpatient surgery in a hospital falls under Part A. Part A pays 100% of costs after the Part A deductible.
If you have outpatient surgery, Part B covers the operation and prosthetics. Part B also covers prosthetics that you wear, as long as you get them from a Durable Medical Equipment supplier that participates in Medicare. After you meet the Part B deductible, you’ll pay 20% of the cost.
Medicare covers many types of prosthetics, including:
- Artificial limbs
- Breast prostheses after a mastectomy
- Cochlear implants and certain other types of surgically implanted prostheses
- Ostomy bags and supplies
- Eyeglasses or contact lenses after cataract surgery
Those with a Medicare Advantage plan need to consult the company that handles their insurance to determine the costs. Advantage plans must cover at least as good as Medicare. But, the Advantage plan has a more strict doctor and supplier network that you must follow for coverage.
Tip: Many Medigap plans cover the Part A deductible and any coinsurance costs, leaving you with little to no out of pocket costs!
Medicare Coverage for Amputees
An estimated 2 million Americans are amputees, mostly because of trauma or diabetes. After 24 months of Social Security disability, you’re Medicare eligible. Unless you have Amyotrophic Lateral Sclerosis or End-Stage Renal Disease, then eligibility begins immediately.
Otherwise, if you don’t qualify for disability, you’ll need to wait until your 65th birthday for benefits to begin.
Part B covers prosthetics, wheelchairs, and some other assistive devices for amputees. The deductible, premiums, and coinsurances are your responsibility.
Tip: If you’re unsure about your Medicare eligibility, contact Social Security.
Does Medicare Cover Prosthetic Legs
Part B covers prosthetic legs if a doctor gives you a referral. You must get them from a supplier that participates in Medicare.
You’ll pay 20% of the cost, plus the Part B annual deductible. Medicare will pay for a medically necessary prosthetic leg.
You may have to pay out-of-pocket for additional features and technology.
How Much Does a Prosthetic Leg Cost
Many factors affect the cost of a prosthetic leg, including your age, size, typical activities, health, and the materials and features. As a result, a prosthetic leg can cost anywhere from $5,000 to $50,000.
Further, the costs can vary depending on if you use other insurance, a facility that doesn’t accept Medicare, and your doctor’s fees. Discuss costs with your doctor beforehand.
Tip: If you only have Medicare, consider shopping around for a Durable Medical Equipment supplier. You may find the prosthetic for less cost.
How Much Does a Prosthetic Arm cost
Part B covers prosthetic arms the same as legs. You pay the premium and meet the deductible. Then, you pay 20% of the costs.
Like prosthetic legs, there is a wide array of options for prosthetic arms. Costs can range from around $3,000 to $30,000.
But, advanced myoelectric arm costs fall around $20,000 to $100,000 or more depending on the technology. Medicare may not pay for advanced features if they’re not necessary.
If you want a 3D printed arm custom fit in about 40 hours, Open Bionics has the cost of the “Hero Arm,” starting around $3,000. But, they don’t have a clear indication of insurance acceptance. Since they have private clinics, I imagine the costs are all out of pocket.
Although, if you’re spending that much on a prosthetic even with coverage, that might be something to consider.
If I Have Medicare Plan G, What is My Deductible For a Prosthesis
Plan G is the most comprehensive Supplement plan available to those eligible for Medicare in 2020 or later. With Plan G, you’ll pay a premium and the annual deductible of $198 for 2020.
After that, the plan will pick up the full cost of the prosthesis. If you have a prosthesis implanted while you’re a hospital patient, Plan G will pay your Part A hospitalization deductible and coinsurances.
Tip: If you know you’re going to visit a doctor often, Medigap Plan G can save you thousands of dollars.
Does Medicare Cover Cranial Prosthetic
Medicare doesn’t cover hair prosthesis unless it’s necessary for treatment. Since a wig won’t improve your health condition, it’s unlikely that insurance will cover any costs.
But, the cost of wigs for people going through cancer can be a tax-deductible expense, so save those receipts!
Further, if you have an Advantage plan, you may get reimbursement for one wig. Contact your policy before you assume reimbursement.
How Much Does a Prosthetic Ear Cost
Medicare covers cochlear implants to improve hearing, severe hearing loss test scores that show less than 40% word recognition qualify
Implants work differently than hearing aids, and they’re an option for people that have difficulties even with a hearing aid.
Cochlear implants can cost as much as $100,000 without insurance, but you can expect to pay much less if you have Medicare. Part B covers implants inserted in a healthcare provider’s office or outpatient facility.
Medicare will pay 80% of the Medicare-approved rate for the implants and surgery. Then, if you have Medigap, that policy can pick up the other 20%. Every time Medicare approves a claim, the Medigap company must also approve.
Does Medicare Cover Prosthetic Eyes
Medicare covers prosthetic eyes if your doctor orders them. Once you meet the Part B deductible, Medicare pays 80% of the cost.
Further, Part B covers replacement prosthetics every five years. Also, Medicare covers polishing and resurfacing twice each year.
Part B will cover the surgical procedure to insert the implant into the orbital socket. Also, the costs for the surgery fall under Part B.
Does Medicare Cover Breast Prosthetics
Medicare covers surgically implanted breast prostheses after a mastectomy. If you have surgery as an inpatient, Part A covers your prosthetics.
Part B covers your prosthetics if you have outpatient surgery. Your costs are different in Part A than in Part B.
With Part B, you pay a small annual deductible, and Medicare then pays 80%. With Part A, you pay a larger deductible and 20% of the cost.
Part B also pays for external breast prostheses, bras, and post-surgery camis. But, you must buy from a supplier that participates in Medicare.
How often will Medicare pay for prosthesis and bras for breast cancer survivors?
External breast prostheses need replacement periodically, and Medicare will pay for replacement devices.
Medicare adheres to this coverage schedule:
- One silicone breast form every two years, or one foam breast form every six months
- If you had surgery on both breasts, Medicare would pay for two
- Mastectomy bras with a doctor’s prescription have coverage for about 4-6 bras each year
- Medicare may cover new bras because of changes in your weight or other reasons
- Up to three camis a month, if necessary
Does Medicare pay for custom breast prostheses?
Medicare covers standard external breast prostheses. It won’t pay for custom versions, even for women having trouble with off-the-shelf products.
But, legislation has been introduced in Congress that would provide coverage. As of now, there is a CPT Code for custom breast prosthesis, but coverage isn’t available yet.
Medicare Prosthetics in a Skilled Nursing Facility
Part A covers up to 100 days in a skilled nursing facility after you’ve been hospitalized for at least three days. If you get a prosthetic while you’re in the skilled nursing facility, it’s covered by Part A at 100%.
The SNF must enroll as a supplier with the National Supplier Clearinghouse to bill for Durable Medical Supplies such as prosthetics.
If you’re a long-term nursing home resident, Part B will cover your prosthetics. You may also have prosthesis coverage under Medicaid.
Get Help Paying for Medicare Prosthetic Devices
You have options for prosthetics and any relating supplies that are unique to your situation. We can help you!
Our team can find a plan that fits your health and budget needs. We’ll compare plan prices, answer questions, and help you in the right direction.
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