Are Prosthetics Covered by Insurance?
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Medically necessary prosthetics are usually covered by health insurance, though the amount of coverage will vary based on the type of prosthetic, the policy itself and if it carries any exclusions. For example, some health insurance plans may cover up to 50% of the cost of a prosthetic arm, while Medicare will generally cover up to 80%.
In 2005, about 1.6 million experienced limb loss and this number is expected to more than double by 2050. Learn what factors influence the cost of prosthetics as well as options if your healthcare won't cover these specialized pieces of equipment.
How Much Do Prosthetics Typically Cost?
The cost of prosthetic devices, whether insured or not, can greatly differ based on several factors. The type of prosthesis is a primary determinant; complex arm and lower limb prosthetics are usually costlier than partial foot or hand prosthetics. For instance, out-of-pocket expenses for below-the-knee external devices range from $6,500 to $35,000, while above-the-knee arm prosthetics can cost from $8,000 to $80,000.
The materials and technology used in the prosthetic also significantly influence the price. Traditional prosthetics made from materials like wood or plastic might cost a few thousand dollars. However, prosthetics with advanced technology, such as microprocessor-controlled joints or bionic systems, could incur an out-of-pocket cost ranging from $40,000 to $120,000 without coverage.
Children may need frequent replacements or adjustments due to their physical growth, while adults generally typically require a new limb every three years. Additional costs include prosthetic accessories like socks and liners, ongoing physiotherapy and rehabilitation and specialized usage training.
How Much of My Prosthetic Will Insurance Cover?
In general, insurance will cover 20% to 50% of the cost of a bionic arm but this can change based on the body part the prosthetic is needed for, as well as your plan’s specifics. For instance, Medicare covers 80% of the cost and you cover the remaining 20%.
Keep in mind that a deductible will likely apply as with most plans. Your prosthetic coverage will not start until this deductible is met. After meeting your deductible, you could still face cost-sharing expenses via coinsurance or copayments for services or items related to your prosthetics. Once you reach your out-of-pocket maximum — the yearly limit on what you could pay for covered services — your insurance typically covers 100% of the allowed amount for covered services.
Be mindful of your plan’s coverage limitations and exclusions. Your plan might cap prosthetics reimbursement or exclude specific prosthetics types and you may need pre-authorization or a "Certificate of Medical Necessity" before you can receive prosthetics-related treatment.
What Types of Insurance Plans Cover Prosthetics?
There is no one-size-fits-all when it comes to getting coverage for your prosthetic. For this reason, we’ve provided breakdowns of how each type of health plan typically handles prosthetic coverage.
Employer-sponsored health insurance often covers prosthetic devices. Small businesses in particular that offer healthcare benefits are legally bound to cover essential benefits, like prosthetics, under the Affordable Care Act (ACA). Larger businesses still tend to cover prosthetics to some extent.
Like small businesses, individual health insurance plans purchased through the Health Insurance Marketplace must cover essential health benefits, including "rehabilitative and habilitative services and devices," which can possibly encompass prosthetics. Still, the specifics, such as the types of prosthetics covered and the percentage of cost covered, can differ from plan to plan.
These are health insurance plans you buy directly from an insurance provider or through an agent outside the official Health Insurance Marketplace. While they may cover prosthetics, they are not bound by the ACA's requirements to cover essential health benefits.
Your Medicare program covers prosthetics under Part B of Original Medicare and possibly Part A if the prosthetic is surgically implanted. Coverage will include fitting and alignment and necessary physiotherapy. Keep in mind you will need to get your prosthetic from a Medicare-enrolled supplier.
In most states, Medicaid programs cover prosthetics with Mississippi being the only recorded exception. Each state sets its own limits and exclusions. Some may only cover one prosthetic per lifetime, while others may exclude certain types of prosthetics. Others may require prior authorization and some have no limits on service.
Alternative Financial Aid for Prosthetic Devices
When insurance coverage is insufficient or not an option, alternative financial aid sources are available to help mitigate the costs of prosthetics. For instance, the Amputee Coalition, Limbs for Life and the Challenged Athletes Foundation and other nonprofits all offer grants and assistance programs specifically tailored for individuals who require prosthetic devices.
Additionally, government programs can also be a significant source of support. For example, the Department of Veterans Affairs and Prosthetic and Sensory Aids Service provide veterans who wear prosthetic devices an annual clothing allowance if their device rips their clothing and structural changes to their home entrances and bathrooms to better accommodate their mobility needs.
The rise of crowdfunding platforms, such as GoFundMe, have provided another avenue for financial assistance. These platforms have grown increasingly popular and effective for raising funds to cover a range of medical costs, including those associated with prosthetics. And while this isn’t financial aid, some prosthetic developers offer relatively inexpensive devices for those who can’t afford something on the higher end of the price range.
Financing through a credit company like CareCredit or directly through the prosthetics supplier is another option if your insurance won’t cover you. For example, Unlimited Tomorrow, a manufacturer of robotic prosthetic arms, has financing options for their True Limb bionic hand at $279 per month.
How Do I Get Health Insurance That Covers Prosthetics?
To get health insurance that covers prosthetics, you can follow these steps:
- Understand your current health insurance coverage: Your current insurance may already offer coverage for prosthetics. Make sure you understand any out-of-pocket costs and exclusions your plan may include.
- Consider your options: Prosthetic coverage can come from multiple places, such as group healthcare plans, ACA plans, Medicare and so on. Consider your budget and what's available.
- Research providers: Check their policy documents, coverage details and network of healthcare providers to ensure they meet your needs.
- Compare plans: Pay attention to factors such as premiums, deductibles, copays and out-of-pocket maximums. Consider not only the coverage for prosthetics but also other healthcare services you may require.
- Speak with insurance representatives: Inquire about pre-authorization requirements and any limitations or exclusions.
- Consult with a healthcare professional: Doctors and specialists may have experience working with different insurance carriers and can offer valuable insights.