Medicare is the national health insurance program for people aged 65 and older in America. Some younger individuals can qualify early due to disability as well. Medicare provider coverage for a number of prosthetic devices. Let’s review which items qualify and how the coverage works.
What is considered a Prosthetic Device?
A prosthetic device is used to replace a body part that is either lost or maybe no longer functioning as it should. There are several different causes as to why a Medicare beneficiary might need such a device. Perhaps the device would help to increase the beneficiary’s mobility. Another reason might be that the device allows the beneficiary to live independently or care for him or herself.
Sometimes a surgery may involve the use of a prosthesis as well.
Prosthetic Device Examples
There are a number of types of prosthetics. These include artificial limbs and eyes, breast prostheses, orthotics, braces for arms and legs and back, cochlear implants, orthotics, ostomy bags and supplies, and urological supplies. Eyeglasses and contacts can also be considered prosthetics.
Medicare’s Coverage of Prosthetics
Medicare offers coverage for both inpatient and outpatient treatment. Prosthetic devices fall under Medicare Part B. After you first satisfy a small annual outpatient deductible, Part B pays for 80% of any medically necessary durable medical equipment. The other 20% of the expense falls to the Medicare beneficiary to pay.
Guidelines for Coverage
Medicare has rules that apply to specific prosthetic devices. Some prosthetics have more specific guidelines than others. Here are a few of the most common prosthetics and how Medicare covers them.
Eyeglasses and/or contacts
Medicare Part B only covers one pair of eyeglasses or contacts if the beneficiary has gone through a cataract procedure. Other than that, Original Medicare does not usually cover anything involving vision. However, some Part C Medicare Advantage plans do offer limited coverage for routine vision services like eye exams.
For amputees, Medicare Part B will cover artificial limbs when the beneficiary has met the criteria to prove that the limb is medically necessary. The prosthetic must be ordered by a Medicare physician. There is considerable paperwork for documentation of medical necessity which involves the patient’s history, ant prior prosthetics used, health conditions and how the device will help the patient return to regular activities of daily living. You must also be very motivated to use the new prosthetic device so your doctor should list the kinds of activities that you are looking forward when you receive the device.
Ostomy & Urological Supplies
Part B will cover ostomy supplies after you have had a colostomy, urinary ostomy, or ileostomy procedure. Medicare will only cover the number of supplies that your doctor specifies. Likewise, Part B will also cover catheters and urinary accessories when they are documented as medically necessary by your Medicare doctor.
Medicare Part B also provides for breast prostheses after a mastectomy. We should also note that Medicare Part A will cover the mastectomy surgery and any related stay in an inpatient hospital.
Orthotics and Orthopedic Shoes
When you have an alignment problem, Part B may cover an orthotic device to help correct the problem. Common examples include orthopedic shoes or inserts.
Cochlear implants are a type of prosthetic device that can improve hearing. allow people with hearing loss to be able to better hear. Part B will cover these when there is documented hearing loss.
Additional Medicare Guidelines
Prosthetics are offered by suppliers such as Orthotic & Prosthetic Centers. Your prosthetic supplier must participate in Medicare in order for Part B to cover your prosthetics.
It’s important to verify that your supplier accepts Medicare’s assigned rates as well so that you don’t incur any Part B excess charges. These charges can be up to 15% more than Medicare would normally pay.
Ask your physicians and suppliers if they accept Medicare’s assigned rates so that you’ll know exactly what out-of-expenses you might incur.
If you have Medicare Supplement insurance, some policies include coverage for excess charges. Also called Medigap plans, these policies help to cover the deductibles, coinsurance, and copays that Medicare leaves for you to pay.