Important Information About How Insurance Works with Advanced Prosthetics
As soon as a person realizes they will need a prosthetic device, this is usually followed by two questions:
“How much will it cost?”
“Will my insurance cover it?”
To address the first query, the cost of a prosthesis is dependent on the type of components and amputation level. Advanced prosthetics, such as those with internal computers or that are constructed to perform higher-functioning activities, wind up costing more than basic ambulatory prosthetics. Since there are many different types of prosthetic devices, the price range varies.
For instance, a basic prosthetic leg will cost approximately $6,000 to $10,000. However, advanced versions of prosthetic legs cost well over $50,000. Since a prosthetic device is usually an unplanned expense, some people may have to utilize private funds to help cover expenses not covered by insurance. An experienced prosthetist is invaluable in helping patients understand their options.
This brings us to our second question regarding insurance. Considering how expensive prosthetic devices can be, it’s important to know how much of the cost will be covered. Insurance for prosthetic devices is dependent on a few factors, such as your carrier and the plan you’re on.
The six main types of insurance include:
- Employer-sponsored insurance
- Marketplace insurance
- Medicare and/or Medicare supplements
- VA health benefits
- Workers compensation
After breaking down how insurance for prosthetic devices works for the six different coverages, we will provide some info on how to contact an authorized advanced prosthetics and orthotics supplier.
Employer-Sponsored Insurance for Prosthetic Devices
If you are insured through your employer, you should be able to find your provider’s medical policy on prosthetic devices through their website or patient portal. It’s important to get familiar with the verbiage because many health insurance providers won’t cover a prosthetic that includes a microprocessor-controlled joint unless it’s deemed “medically necessary.” Essentially, the amputation and medical situation must meet certain criteria to qualify, and the criteria must be confirmed by an independent healthcare professional.
Policies surrounding prosthetic devices and what qualifies for coverage can be difficult to understand without a medical background. For further assistance understanding policies, it’s recommended that you contact your health insurance provider directly so they can explain the policy to you in easy-to-understand terms. They can also help you estimate how much your prosthetic device will cost after any applicable co-pays and meeting your deductible.
Marketplace Insurance for Prosthetic Devices
The Health Insurance Marketplace is a government-run website that allows you to compare private health insurance plans. It’s similar to employee-sponsored programs, but instead of your employer doing the insurance provider shopping and selection, you are. Since prosthetic limbs fall under the Essential Benefits umbrella of coverages, the insurance plans you find on the marketplace should cover them. However, when comparing plans, make sure to be mindful of the ones that only cover the prosthetic device if a medical professional deems it necessary. That will add an extra level of complication.
Prosthetic Device Coverage for Medicaid and Medicare
Medicaid does include coverage for prosthetic devices. One prerequisite is that you will likely need to get written confirmation from a doctor that it’s medically necessary. Medicaid insurance for prosthetic devices varies by state. According to the Kaiser Family Foundation’s explanation of Medicaid benefits for prosthetic and orthotic devices, they report that the state of Kansas covers the benefit with no limits on service. For more information, it’s recommended you contact your Medicaid provider.
Medicare also includes coverage for prosthetic devices under Part B of their medical insurance plan. The prosthetic device must be prescribed by a Medicare-enrolled doctor or healthcare provider. Once you have met your deductible, you will be responsible for 20% of the Medicare-approved amount (amount varies by plan) of the prosthetic device. It’s also worth noting the type of prosthetic device that you get approved for may come down to your doctor’s recommendations. For further details about what the plan covers, contact your Medicare provider directly. Most individuals purchase a Medicare supplement policy which usually picks up the remaining 20% of the prosthetic charges.
VA Health Benefits and Coverage for Prosthetics
VA health benefits include a suite of coverages intended to provide preventative care, treat injuries and illnesses, and improve the individual’s quality of life. Some of the patient care services provided include cancer care, audiology, therapy and rehab, and coverage for prosthetic devices. Veterans are encouraged to check the Rehabilitation and Prosthetic Services section in the U.S. Department of Veterans Affairs website.
Workers’ Compensation and Prosthetic Device Coverage
Workers’ compensation programs provide income protection and partial medical care to those who have been injured or become ill at their place of employment. Employees in the manufacturing and construction industries are statistically at a higher risk of being injured on the job. However, workers’ compensation programs apply to all industries.
Keeping that in mind, an employee who is involved in a work-related incident that results in an amputation qualifies for workers’ compensation. That applies to medical expenses, prosthetic devices, rehabilitation, and any relevant therapies.
How to Find an Approved Supplier of Prosthetics in Kansas City
Once you know what your insurance carrier will cover and what you will pay out of pocket, most individuals find it beneficial to speak with an approved supplier of advanced prosthetics. An approved supplier accepts a range of insurance for prosthetic devices, which may include supplemental insurance coverages and government-affiliated specialty programs.
When contacting your local prosthetist, you can ask them to supply you with more details regarding the types of advanced prosthetics your plan qualifies for along with pricing information. Our staff at Cotton Orthotics and Prosthetics are able to assist you in obtaining information about the benefits your insurance includes.