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Does Insurance Cover Prosthesis Costs?

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September 28th, 2020

Prosthesis - Innovative Prosthetics AmeriStep ProstheticsA common question you may have is whether your insurance will pay for your new prosthesis. This ultimately comes down to your individual insurance plan. However, there are several different ways health insurance companies approach coverage for prosthetic devices. The good news is that many health insurance plans do cover prostheses in some way. However, there may be limitations to coverage based on the specifics of your insurance benefits. Therefore, you should research the specifics of your insurance plan. You can also talk to your doctor, prosthetist, and patient care coordinator about costs and insurance coverage based on your plan to find solutions to meet your needs. However, even if health insurance coverage isn’t able to meet your prosthetic needs, there are many other financial assistance options to choose from.

Will My Health Insurance Plan Cover the Cost of My Prosthesis?

Just like coverage for most other services, plans vary when it comes to insurance coverage for prosthetic devices and services. However, many insurance plans do cover prosthetics in some form. It’s important to understand the particulars of your medical insurance plan to know what they will and won’t cover. For example, some insurance plans cover costs for prosthetics that are prescribed by your physician as medically necessary. Some insurance plans will only cover certain types of prosthetic devices. For instance, specialized athletic prostheses may not be covered. Another important thing to think about when looking at healthcare coverage is how often your insurance covers replacements. However, even if insurance doesn’t meet your needs, there are still many options available, so work with your physician, prosthetist, and our team to find the right options for you.

Employer-Sponsored Health Insurance

If you have insurance through your employer, then most cover prosthetics. Under the Affordable Care Act, small group insurance plans must cover the ten Essential Health Benefits, which include prosthetic devices. However, even if you have health insurance from a larger company, many large group insurance plans still offer coverage for prosthetic devices, even through they are not legally required to. Therefore, your health insurance may cover all or part of the costs for your prosthesis. Once again, it’s important to understand the specifics of your individual plan regarding prosthetic coverage.

Marketplace Insurance

Similar to small group insurance plans, marketplace health insurance must cover the Essential Health Benefits, which includes prostheses. However, coverage can vary, so it’s important to shop around and find the insurance that best suits your needs. It’s also vital to understand what your marketplace health insurance coverage includes. Your plan may cover part or all the costs of your prosthesis if deemed medically necessary by your physician.

Medicare

Medicare insurance coverage for prosthetics is based on your physician’s recommendations, so long as the doctor and the supplier are enrolled. The Medicare program uses what is called a K level to determine the type of prosthesis available for coverage. K levels are a system used by the Centers for Medicare & Medicaid Services (CMS) to determine which prosthetic devices are medically necessary.

Your K level is a number between 0 and 4 and refers to the functionality you may gain from your prosthesis. Then, your physician will prescribe a prosthetic device based on this K level and activity level. In most cases, Medicare coverage will not cover prostheses designed for higher activity levels than the one your doctor assigns. Therefore, it’s important to provide as much information as possible to your doctor about your lifestyle, such as activities you do, how many stairs are in your home, and other information that may impact your K level.  

Medicaid

Medicaid also provides some coverage for prosthetic devices. However, coverage varies from state to state. Medicaid coverage for prosthetics is also based on K level and medical necessity. However, there are generally limits to the type of prosthesis that Medicaid will cover. Working with your prosthetic care team can help you find the right prosthetic for your needs and also for your health insurance coverage.

Other Types of Financial Assistance for Prosthetic Devices

However, even if your health insurance doesn’t cover the costs of your prosthesis, or only partially covers prosthetic devices, you still have many options. There are many financial assistance programs to help provide financing for your prosthetic device. Therefore, whether you’re denied coverage by your insurance company or you’re unable to cover the out-of-pocket costs after your insurance pays for your prosthesis, many organizations are here to help provide assistance. Some of the many resources available include:

  • Veterans Administration
  • Department of Human Services
  • Challenged Athletes Foundation
  • Local non-profits
  • Churches
  • Civic clubs
  • Vocational Rehabilitation Services
  • Limbs for Life Foundation
  • Amputee Coalition
  • Barr Foundation

In addition, many patients choose other financing options to cover the costs of their prosthesis, such as loans through financial institutions or healthcare credit cards like CareCredit. This all depends on your needs, prosthetic device, and specific circumstances. If you’re interested in learning more about financial assistance for your prosthesis or aren’t sure what the right course of action is for your individual needs, reach out to our team. Our patient care coordinators can help provide information and also locate community resources for prosthetic financial assistance available. We also offer financial counseling for your prosthesis and care needs.

Choose Innovative Prosthetics for Individualized Prosthetic Care

At Innovative Prosthetics, we are here to provide quality, compassionate care. Our team can help you research your insurance benefits regarding prosthetic devices and work with you to find solutions based on your insurance coverage and your needs. We also assist with financial counseling and helping you find resources to suit your circumstances. Our goal is to help you live forward by offering specialized prosthetic care, from fabrication to ongoing care. We believe in providing a unique, personalized experience for every patient to help you maximize your potential. Schedule an appointment today to learn more and take the first step. At Innovative Prosthetics, we are here to provide you with the custom, quality care you need.

Every prosthesis is unique just like our patients.

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