Does Medicare cover prosthetics?

If you or a loved one is an amputee and looking for financial help in obtaining prosthetic devices, Medicare may be able to help. Medicare Part B covers some prosthetic devices when they are needed to replace a body part or function. The prosthetics must be ordered by a doctor or healthcare provider who participates in Medicare. Prosthetics covered by Medicare may include:

  • eyeglasses or contact lenses for use after a cataract operation
  • ostomy bags and related supplies
  • urological supplies
  • limbs
  • breast prostheses (including surgical bras) for use after a mastectomy
  • cochlear implants
  • certain other surgically implanted prosthetic devices

As you can see, there exists a lot of leeway in terms of what Medicare will cover, so it is crucial to consult with your doctor and obtain his or her recommendation before contacting Medicare. In terms of costs, you will usually pay 20% of the Medicare-approved amount for external prosthetics. Additionally, you will have to pay your Medicare Part B deductible. The “Medicare-approved” amount is the price that Medicare sets for a given prosthetic, which may not match the actual purchase price from a prosthetic dealer or manufacturer. For example, if you need a prosthetic limb that a manufacturer sells for $2000, the Medicare-approved amount for that limb may only be $1500. You will have to pay the difference of $500, plus 20% of the approved $1500 amount, plus your deductible.

It is also worth noting that Medicare will only pay for prosthetic items furnished by a supplier that is enrolled in Medicare, so be sure to check if your supplier is before placing an order.

Due to high instances of Medicare fraud in relation to prosthetics, the federal government has recently proposed significant changes to its coverage plan that could affect the ability of amputees to obtain coverage. Medicare is seeking to establish stricter requirements for obtaining advanced prosthetics. It is also trying to eliminate some of the universal codes employed by prosthetic suppliers, according to CNN. The Wall Street Journal reports that amputees may not be reimbursed for artificial limbs if they use other assistive devices like crutches or a cane. Medicare, for its part, is looking to curb fraudulent activities by both suppliers and patients that resulted in over $43 million in inappropriate payments in 2009.

Opponents of Medicare’s proposal say that the rule changes could even expand to third party insurance companies. That would adversely affect the estimated 1.6 million Americans who have lost a limb. How does the new proposal affect you, the patient? That’s hard to say, but it is in your best interest to consult with your doctor and a Medicare specialist sooner rather than later. You can contact Medicare by phone at 1-800-633-4227.

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