Does Medicare Cover Prosthetics?
Yes, Medicare does offer prosthetic coverage, but only when deemed medically necessary by a treating physician. The prosthetic device must also be supplied by a Medicare-enrolled provider. Generally, approved Medicare prosthetics and related devices and equipment include:
- Artificial limbs
- Non-cosmetic breast prosthetics (post-mastectomy)
- Surgical implants
- Eye prosthetics
Medicare covers prosthetic devices over several Parts, which means beneficiaries must maintain their monthly premiums and may need to meet the deductible before earning benefits. Read on to make sure you can access the Medicare prosthetic coverage you need.
Table of Contents
What Is Considered a Prosthetic?
Medicare defines a prosthesis as a device ordered by a Medicare-approved physician or other medical professional, that is required to replace a body part or bodily function. Medicare-approved prosthetics include:
- Prosthetic limbs needed to replace arms, hands, feet, legs, or other body parts
- Surgical implants (such as cochlear implants)
- Post-mastectomy prosthetics including breast implants and medical accessories
- Ostomy bags and urological supplies
- Cataract surgery supplies and related expenses, and ocular implants
- Therapeutic shoes for Diabetes-related ailments
- Neck or back braces
Medicare will not cover prosthetics deemed medically unnecessary by doctors, including:
- Dentures or dental veneers
- Cosmetic breast implants
- Hair implants or wigs to treat hair loss
- Eyeglasses or contact lenses for non-specific eye conditions or general vision limitations
How Does Medicare Coverage for Prosthetics Work?
Generally, Medicare covers most external prostheses through outpatient Part B benefits, though other prosthetic procedures or equipment may incorporate other Parts of Medicare.
Eligibility requires patients to obtain an order for the prosthetic device from a Medicare-enrolled doctor. The order must outline the specific reasons for needing the prosthesis and deem the procedure or equipment “medically necessary” to replace a body part or bodily function.
Eligibility for Medicare prosthetics coverage also depends on the supplier of the device. Like the healthcare provider who orders the prosthesis, the supplier must be enrolled in Medicare. You can check Medicare.gov for participating doctors and suppliers, or request a list of eligible participants through your Medicare Advantage plan, if applicable.
Part A Coverage
Part A typically covers inpatient hospital benefits for Medicare beneficiaries. Most beneficiaries who paid into social security benefits while working for at least 10 years do not owe a monthly premium for Part A, but they must still meet their annual deductible to get Medicare prosthetic coverage.
Part A coverage only applies to prosthetics like cochlear implants that require surgical implantation. In the case of a medically necessary surgical implant procedure, Medicare Part A covers the first 60 days in the hospital at no cost to you, provided you meet your Part A deductible and premium, if necessary. Part A will also cover a 20-day stay in a rehabilitation or nursing facility after your hospitalization.
Part B Coverage
Part B typically covers outpatient medical care, which includes the bulk of expenses for external prosthetics such as artificial limbs and other durable medical equipment. Medicare sets annual Part B premium and deductible costs, which must be maintained and met to receive benefits for prosthetic devices.
Once your deductible is met and you meet the criteria for the approved prosthetic device, Medicare will cover 80% of the costs associated with fitting, applying, and maintaining the prosthesis through outpatient care services. You are responsible for the remaining 20% of the costs and, if the full cost exceeds the Medicare allowance, 100% of the excess costs.
Part C Coverage
Part C, or Medicare Advantage, is Medicare coverage that is purchased separately through a private insurer. Part C coverage typically offers additional medical benefits not included in Original Medicare such as vision, hearing, and dental services. Part C plans are required to provide the same benefits as Original Medicare at a minimum, but may offer additional coverage for expenses like eyeglasses, dental implants, or optional hearing implant devices.
Where Can You Obtain a Prosthetic?
Once you obtain an order from a Medicare-approved doctor for a prosthetic device, the source of the prosthetic must also accept Medicare assignment. Medicare requires providers of prosthetic devices to meet certain quality standards in order to receive a Medicare supplier number.
Prosthetic limbs, orthotics, and other surgically implantable prosthetic devices comprise various categories of durable medical equipment. Suppliers must receive accreditation through one of 10 national accrediting agencies under Medicare to distribute durable medical equipment to Medicare beneficiaries. Patients can search for eligible providers in their area through CMS.gov.
Costs Associated With Prosthetics
While Medicare covers the majority of expenses associated with medically necessary prosthetic devices, prosthetics covered by insurance may still require out-of-pocket costs.
Since Medicare Part A exclusively covers inpatient care and hospital visits, these benefits only apply to cases in which a prosthetic device must be surgically implanted. In this case, Medicare covers the full cost of a hospital stay of up to 60 days and, if necessary, another 20 days in a nursing facility before you owe anything out-of-pocket. You must pay the Part A deductible ($1,600) before benefits kick in.
Medicare Part B covers 80% of the cost of outpatient care such as fittings and maintenance of prosthetic devices, provided you pay your Part B premiums ($165) and deductible ($226). While Medicare covers the majority of expenses for prosthetics, you may owe out-of-pocket fees for costs including equipment repairs or replacements beyond Medicare’s annual limits.
The cost of a Medicare Advantage plan varies depending on the insurer offering the policy and the benefits included in the plan. Part C replaces your Original Medicare enrollment, but you would still pay your Part B premium along with the premium for your Medicare Advantage Plan. You may owe out-of-pocket expenses if your Part C plan does not cover the durable medical equipment you need or your requirements exceed your individual policy limits.
Alternatives to Medicare Coverage
Certain prosthetics may not get Medicare approval if they are deemed more cosmetic than medically necessary, and Medicare may deny a claim for a prosthetic device not ordered by a Medicare-approved provider. Medicare coverage might also exclude the type of prosthetic you need.
If Medicare does not apply, you may need to pursue prosthetic coverage through another non-Medicare source. Medicaid, or state-funded healthcare, typically covers at least a portion of many prostheses. Additionally, ACA-regulated small group plans must cover essential benefits, which include prosthetics.
All in All
Medicare may cover prosthetic devices like artificial limbs and cochlear implants through Parts A, B, or C. To receive benefits for prosthetics, your doctor must attest to your need for durable medical equipment out of medical necessity. You must also make sure your prosthesis is provided by a Medicare-approved supplier.
Medicare covers most prosthetics through outpatient Part B benefits, including repairs and replacements up to a set limit. Part A benefits may apply to prosthetics that are surgically implanted. You may also extend your prosthetics benefits through a Part C plan. While Medicare offers multi-Part coverage for prosthetics, it does not apply to cosmetic prosthetic devices.