What Does Medicare Cover for Prosthetic Devices?
- Discover which prosthetic devices you can claim for with Medicare, and find out about the specific criteria you need to meet to be eligible for coverage.
Artificial devices that act as replacements for body parts and bodily functions are called prosthetics. There are numerous prosthetic devices that serve a variety of functions, from breast prostheses following a mastectomy to cochlear implants for the hard of hearing. Artificial limbs, ostomy bags and supplies to support their functions are other examples.
In this article, you'll learn about which prosthetic devices Medicare covers, any exceptions and the costs associated with coverage.
What Does Medicare Cover for Prosthetic Devices?
If part of the body stops working, is damaged or has been removed, science has advanced to provide modern solutions in the form of functional prosthetic devices. In many instances, you can opt to use a prosthetic device that replaces the body part or function in question.
Medicare can often help you pay for some or all of your treatment, depending on your insurance plan and what's deemed medically necessary. Some of the prosthetic devices Medicare is likely to cover include:
- Breast prosthesis following a mastectomy, as well as a surgical bra
- A pair of glasses or contact lenses following surgery for cataracts
- Prosthetic limbs and eye implants
- Some surgically implanted devices, such as cochlear implants
- Back, leg, arm and neck braces
- Ostomy bags and related supplies
- Catheters and drainage bags
If a device is lost, destroyed, damaged beyond repair or becomes unusable because of an emergency, Medicare might cover the cost of a replacement. It's important to note that all prosthetics must be supplied by a Medicare-enrolled provider.
Are There Limitations to Coverage?
Medicare usually provides coverage for prosthetic devices, but there are certain restrictions in place.
- Some states might require prior authorization from Medicare for specific types of lower limb prosthetics.
- Whatever the prosthetic device is for, it must be designed for use in your home or a long-term care facility to be deemed durable medical equipment.
- Any prosthetic implants, devices or items must be provided by a Medicare-approved supplier.
How to Get a Prosthetic Device Through Medicare
For Medicare to cover a prosthetic device, a physician must deem it medically necessary as a replacement for a body part or bodily function. The prescribing doctor must:
- Explain why the device is medically necessary
- Recommend a prosthetic from a Medicare-approved supplier
- Be enrolled in a Medicare program themselves
The Medicare government website includes handy tools you can use to locate a provider and a supplier that's in-network with Medicare. If you have coverage from Medicare Advantage, you'll need to check with your private insurance provider to make sure your provider and supplier is in your network.
If you have a Medicare plan and require a prosthetic device, Medicare can help you pay for it. Coverage depends on your plan, and there may also be deductibles, copays and coinsurance that you'll need to pay yourself. Below is an explanation of how the different types of Medicare might help you cover the costs of prosthetic devices.
Original Medicare includes Part A and Part B, which cover inpatient and outpatient treatment, respectively. If you receive a surgical implant in a hospital or other inpatient setting, Part A will cover the procedure. Most people don't pay a premium for Part A, so you'll need to meet your deductible but won't be expected to cover any other copayments for up to 60 days in hospital.
Part B covers prosthetics that don't require surgery, such as orthotics and surgical bras. For all external prosthetics, you'll pay 20% of the costs and Medicare covers the remaining 80%. Be careful not to select a device that exceeds the amount permitted by Medicare, or you'll have to pay 100% of the excess. The Medicare Part B deductible is $203, and you'll need to meet this before your insurance kicks in.
Medicare Part C
Medicare Advantage covers the same medically required procedures as Part A and Part B except it's provided by a private insurer. You should check with your provider to find out about the costs associated with your prescribed prosthetic device. Many Medicare Part C plans come with additional coverage for prescription medication.
Medicare Part D
You can get Medicare Part D private insurance to help cover outpatient prescription drug treatment. Following surgery for your prosthetic device, you might be prescribed drugs to take at home, which Part D might cover. Be sure to check that the medication is on your formulary to make sure you're entitled to claim for it.
Which Prosthetics Aren't Covered by Medicare?
It's important to note that not all prosthetic devices are deemed medically necessary. Some implants and devices are considered cosmetic, which means Medicare won't cover them. Unless you have a Medicare Advantage plan that provides coverage, the following devices are unlikely to be included in Medicare:
- Wigs or head coverings
- Most eyeglasses and contact lenses
- Cosmetic breast augmentation