- Medicare covers several health devices like prosthetics.
- Prosthetics falls under Medicare Part B coverage for durable medical equipment.
- You may need to meet specific criteria to ensure your prosthetic is covered.
Prosthetic limbs may be the first things that come to mind when you think of prosthesis devices. However, several other items are also included in this category, and Medicare offers coverage whenever they’re considered medically necessary.
Prosthetic devices are covered under Medicare Part B as durable medical equipment (DME). In many cases, the cost is almost entirely covered.
Find out what you need to know to get coverage for your prosthetic device.
Prosthetic devices include a wide variety of items to help any part of your body that’s damaged, that’s been removed, or stops working.
Body parts like arms or legs might come to mind when you think of prosthetic devices, but this category includes far more devices.
Some of the prosthetic devices covered by Medicare include:
If you need an external prosthetic device, it’ll be covered as DME under Medicare Part B. If you’ve chosen a Medicare Advantage (Part C) plan instead of original Medicare (parts A and B together), your plan will still cover this equipment.
Medicare Advantage plans must cover at least as much as original Medicare does, and many also offer additional coverage. If you have a Medicare Advantage plan, check your plan details to find out exactly what’s covered and how much you’ll have to pay.
With Medicare Advantage, you may be limited to certain in-network suppliers or facilities when it comes to obtaining your device, depending on your plan’s rules.
If your prosthetic device is surgically implanted, this usually requires a hospital stay. In this case, your device will then be covered under Medicare Part A, which covers inpatient hospital care.
To have your prosthetic device covered by Medicare, it has to be ordered by your doctor as a medically necessary replacement for a body part or bodily function.
The doctor prescribing the device must:
- be enrolled in the Medicare program
- detail why you need the device
- confirm that the device is a medical necessity
You must also make sure that the supplier providing your device is enrolled in the Medicare program.
If you have Medicare Advantage plan, you may be restricted to certain providers or suppliers within your coverage network. Check with your plan before renting or ordering any equipment.
You may also have additional coverage with a Medicare Advantage plan.
While only medically necessary items in certain situations are covered under original Medicare, a Medicare Advantage plan may have extra coverage for things like glasses or hearing aids.
Your plan can provide details on exactly what items are covered and how much they’ll cost.
Not every prosthetic device is considered medically necessary. A number of prosthetics and implants are considered cosmetic, so they’re not covered by Medicare. Some devices that wouldn’t be covered include:
- cosmetic breast implants
- eyeglasses or contact lenses for most patients
- wigs or head coverings for hair loss
Some of these items may be covered by Medicare Advantage, depending on your plan. Medicare Advantage plans usually include extra coverage that original Medicare doesn’t, including care for:
If there are devices you need or ones you want your plan to cover, you can search for a plan that includes those items when signing up for Medicare Advantage.
When is eyewear covered?
Medicare will cover glasses or contacts only if you’ve had cataract surgery with an implanted intraocular lens. In this case, Medicare will cover one of the following:
- one pair of eyeglasses with standard frames
- one set of contact lenses
As with most medical equipment covered by Medicare, if you qualify for glasses or contact coverage, it’s still not completely free. You’ll pay 20 percent of the Medicare-approved amount for your corrective lenses, as well as your Medicare Part B premium and deductible.
If you choose frames or lenses that exceed the amount allowed by Medicare, you’ll have to pay 100 percent of the cost beyond the Medicare-approved amount.
Your prosthetic device will be covered by Medicare in the same way as other DME or implants if it meets the following criteria:
- medically necessary
- not simply cosmetic
- ordered by a physician that participates in the Medicare program
- obtained from a supplier that participates in Medicare
Costs with Part A
If your prosthesis needs to be surgically implanted, it will be covered under Medicare Part A as part of an inpatient procedure.
This means you’ll pay your Part A deductible and premium (although most people won’t pay a premium for Part A). Beyond that, you’ll have no copayment for your first 60 days in the hospital.
If you require a stay in a skilled nursing facility or rehabilitation center after your surgery, it’ll be covered by Part A as well.
You’ll pay nothing extra for the first 20 days of care in a skilled nursing facility. After that, daily costs increase as your stay is extended.
Any additional equipment you need while you’re in the facility — such as a wheelchair, walker, orthotics, and more — will be covered by the facility and Medicare.
Costs with Part B
Many prosthetics, like surgical bras and orthotics, don’t require surgery. They can be used as complementary devices at home. In this case, Part B will cover the device under its DME category.
If you’ve met the criteria for coverage, Medicare will cover 80 percent of the approved equipment cost, and you’ll pay the remaining 20 percent. If your device cost exceeds the amount allowed by Medicare, you’ll pay 100 percent of the excess.
You must also pay your monthly Part B premium and meet your annual deductible before your equipment is covered.
Costs with Part C
The amount you’ll pay for a prosthetic device with a Medicare Advantage plan is much more variable. All Medicare Advantage plans have to offer at least the same coverage as original Medicare, but most plans offer more.
Exact coverage and cost will depend on the plan you choose. Discuss coverage and cost specifics when signing up for your Medicare Advantage plan, if possible.
Costs with Medigap
Another option for coverage of prosthetic devices is Medicare supplemental insurance, also known as Medigap.
Medigap plans are private insurance products that can be used only with original Medicare, and not with Medicare Advantage.
Costs vary by plan, but these policies can help offset your out-of-pocket Medicare costs. Some examples of what Medigap plans can be used for include:
- Part A coinsurance, copayment, deductible, and hospital costs
- Part B coinsurance, copayment, deductible, and excess costs
What if I have more questions about prosthesis coverage?
If you have specific questions about prosthetic device coverage, you can contact Medicare or your local State Health Insurance Assistance Program (SHIP) center. Your doctor also may be able to provide information and supplier lists.
If you’ve been denied coverage for a device, you can appeal the decision by filing an appeal with Medicare.
- Medicare covers prosthetic devices as long as you meet certain criteria.
- Medicare Part B covers most external prosthetic devices; Medicare Part A covers devices that must be surgically implanted.
- Only medically necessary devices are covered, and you’ll pay 20 percent of the cost under Medicare Part B.
- Medicare Advantage plans can provide additional coverage, but you should review coverage and costs for prosthetic devices before signing up.
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