Medicare will cover prostheses, such as artificial limbs and eyes, under Part B.
You will usually pay 20% of the Medicare-approved amount after you meet your deductible.
You must use a Medicare-approved supplier to get your prosthesis.
A doctor must write specific instructions and show a medical reason why you need the prosthesis.
If you have experienced limb or eye loss, Medicare will generally pay for a prosthetic device. Prostheses are usually custom-made items that can enhance your mobility. Payment for medical prostheses is typically through Medicare Part B, where the prosthesis is considered durable medical equipment (DME). This means Medicare expects the prosthesis will last at least three to five years.
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Medicare covers medically necessary prostheses when your doctor orders them. They typically aren’t given out at no cost; you usually have to pay about 20 percent of the Medicare-approved amount if you don’t have other insurance types that help reduce the costs. Examples of prostheses Medicare covers include artificial limbs (such as a leg), breast prosthesis after mastectomy, and eyes. Because different materials and customization levels vary, the costs for prostheses can sometimes vary widely.
If you have Medicare Advantage (where a private insurance company fulfills your Medicare benefits), your Medicare Advantage plan must cover prostheses as well. Medicare Advantage must cover the same benefits as Original Medicare. However, the costs may vary based on your plan. You can contact your plan to find out about reimbursement from your insurance policy.
Medicare is insurance for those age 65 and older who paid Medicare taxes while working. However, there are some circumstances where you may be able to qualify for Medicare even if you are not age 65.
You can qualify for Medicare if you are younger than age 65 if you have one of the following conditions:
- You have end-stage renal disease.
- You have amyotrophic lateral sclerosis (ALS).
- Your doctor certifies that you have a disability that keeps you from working.
To qualify as having a disability, you must be unable to engage in “substantial gainful activity” for at least the next 12 months. An estimated 16% of those with Medicare have a disability.
Experiencing limb or eye loss does not necessarily mean you are disabled. But if you find yourself unable to work following an injury or chronic medical condition, your doctor may declare you are disabled. However, you usually have to receive Social Security disability benefits for at least 24 months before you can qualify for Medicare.
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If your doctor writes a prescription for a prosthesis, you will pay 20% of the Medicare-approved amount for the prosthesis and Medicare will pay the remaining 80% . You also must first meet your Part B deductible before the 20% applies.
Another important factor to consider regarding Medicare reimbursement is that you must obtain your prosthetic device from a supplier enrolled in Medicare. Otherwise, Medicare will not reimburse the costs.
How much does it cost to get a prosthetic leg?
Prosthetic legs must be custom-fitted for the individual. The materials and design can vary, which may affect the price. A prosthetic limb can vary in costs from $5,000 to $50,000. A company that produces the prosthesis must accept assignment from Medicare. This means the company contracts with Medicare and accepts the Medicare-approved amount to create the prosthesis. If you go to a company that does not accept Medicare assignment, Medicare is unlikely to reimburse you for the prosthesis.
Medicare will cover a portion of the costs for an artificial eye. Medicare Part B is the portion that covers this prosthesis.
There are a number of reasons you may need an artificial eye. These include:
- Absence of an eye due to a congenital (at-birth) condition
- History of trauma to your eye
- History of a medical condition (such as cancer) that required surgical removal of your eye
You will pay 20% of the Medicare-approved amount for the prosthetic eye. However, a doctor must write a prescription that says you can benefit from the prosthesis. For the purposes of the prosthesis, Medicare calls this a “Standard Written Order” or SWO. A prosthesis company will also need medical record information to show the need for the prosthesis, a code that specifies why you need the prosthesis, and proof of delivery.
How much does it cost for a prosthetic eye?
When it comes to an artificial eye or eye prosthesis, there are several options that Medicare will potentially cover, depending upon your needs for replacement. These include:
What extra benefits and savings do you qualify for?
Also known as an artificial or glass eye, replaces an absent natural eye.
Can range from $1,500 to more than $8,000, depending upon eye features
20% of the Medicare-approved amount
Prosthesis that can be worn over a damaged eye.
Can range from $1,500 to more than $8,000, depending upon the prosthesis materials
20% of the Medicare-approved amount
A potential supplier should be able to provide an estimate for the prosthetic eye or scleral shell to help you get a better idea of your costs. Some suppliers may offer payment plans to help make the costs more affordable.
Prosthetic eyes can require both maintenance and sometimes replacement. Medicare will cover polishing and resurfacing of the eye two times per year. If needed, Medicare will also cover a one-time enlargement or reduction of a prosthetic eye.
While some people may keep an eye prosthesis for a decade or more, Medicare will usually cover its replacement every five years, provided a doctor certifies the eye replacement is medically necessary.
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Medicare offers a search function on its website to help you find suppliers that accept Medicare assignment. You can enter needed equipment or your zip code to find a list of Medicare suppliers in your area.
The doctor who wrote your prosthesis prescription may also recommend a prosthesis company that can help fit you for your new prosthesis.
If you need surgery, such as eye surgery, to implant your prosthesis, Medicare Part A may pay for the surgery and implant. This is typically true when your surgery is performed on an inpatient basis. However, if your surgery takes place at an outpatient surgery center, Part B may cover the costs.
Medicare covers prosthetics it considers medically necessary. As a result, any prosthetics with value that’s cosmetic rather than health-related are not covered. Examples include dentures, dental implants, or cosmetic breast implants.