Does Medicare Cover Prosthetics?

Prosthetic technology has come a long way over the past 100 years. Today, replacing a missing limb that has been lost due to an injury, illness or congenital issue can be done with much more precision than in the past.

Today’s prosthetics include improved functionality, and some even combine the use of robotics to aid in completing everyday tasks. Additionally, modern fitting procedures utilize advanced imaging to create more natural, comfortable fits that ultimately add to the longevity of prosthetic usage.

Medicare Benefits Solutions

Jan 17, 2022

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Defining Prosthetics

It’s important to point out that, while most prosthetics fall under the category of replacement limbs and digits, prosthetic equipment can be used to replace a variety of body parts and functions. For example, various ostomy bags are defined as prosthetics. These bags function as prosthetic aids in the collection of bodily waste and other fluids. Additionally, a cochlear implant is a type of prosthetic that takes on the role of the cochlear nerve when the nerve has been damaged.

Does Medicare Cover Prosthetics?

Medicare will cover many prosthetic devices that are deemed medically necessary. Coverage is supplied under Medicare Part B, the outpatient benefit, in most cases. Medicare Part B is optional coverage and typically carries a deductible that must be met before benefits apply. As well, premium payments are generally required in order to keep Medicare Part B coverage current.

If your prosthetic is covered under Medicare Part B, you will need to pay 20% of the cost while Medicare covers the remaining 80%. Doctor visits for evaluations, imaging, fittings and follow-up care will also fall under Medicare Part B in most cases.

If you require hospitalization as a part of your prosthetic care, Medicare Part A, the inpatient benefit, will provide coverage. This is the same part of Medicare that supplies coverage if you need to stay in a skilled nursing facility. Many people who require a prosthetic device will require surgery prior to receiving a prosthetic, so it’s good to know that Medicare will supply coverage.

In terms of the length of inpatient coverage, Medicare Part A offers full coverage for the first 60 days of hospital care or skilled nursing care. From day 61 through day 90, coverage is supplied at a discounted rate that can change from year to year. If you require inpatient care after 90 days, you can still receive discounted care by utilizing any lifetime reserve days that you have left. If these days have been exhausted, inpatient care is billed to you at 100%.

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Medicare Part D and Prosthetic Coverage

Medicare Part D is the prescription drug benefit of Original Medicare. It only covers prescription medications available from retail pharmacies for home use, so it does not pay for prosthetic coverage. With this stated, you may require medication related to prosthetic fittings or care. This may be the case after surgery to amputate a limb or after surgery to place an ostomy bag port.

In these cases, Medicare will cover any prescription medications related to your care as long as these medications are covered in your plan’s formulary. This is a list of all covered medications under your plan along with the amounts and restrictions each medication must adhere to.

Medicare Advantage and Prosthetic Coverage

A Medicare Advantage plan will cover all of the same prosthetic benefits as Original Medicare, but you may be able to access additional benefits like physical therapy specific to adjusting to life with a prosthetic. To learn all of the benefits available to you as they relate to prosthetics and your Medicare Advantage plan, contact your plan provider. You can also work with a licensed insurance broker to find a Medicare Advantage plan that’s right for your unique needs.

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