Does Medicare Cover Prosthetics?
People use prosthetic devices when they need to replace a body part or improve the function of a damaged body part. Prosthetic devices aren’t just for limb replacements—they can also include dental implants and cochlear implants as well.
Medicare provides coverage for prosthetic devices if your healthcare provider orders them. However, Original Medicare doesn’t cover any prosthetics related to oral care.
Key takeaways:
Medicare covers prosthetic devices like breast prosthesis, artificial limbs, and cochlear implants.
Your doctor must prescribe a prosthetic device for it to be covered.In some states, you may need to get prior authorization for specific prostheses.
Medicare doesn’t cover prosthetic devices related to oral care like dentures or dental implants. Some Medicare Advantage plans may cover devices related to dental care.
What are prosthetics?
Prosthetic devices are artificial devices that mimic or replace parts of the body to help restore their function. They typically help people with mobility, hearing, physical appearance, or other impairments. People often need a prosthetic device after experiencing a lost limb or impairment due to injury, illness, or conditions occurring from birth.
Some common examples of prosthetics include:
Prosthetic limbs and joints
Myoelectric prosthetic devices (devices that use electrical signals from muscles to control movement)
Cosmetic prosthetic devices (for breast reconstruction, facial reconstruction, etc)
Dental prostheses (dentures and dental implants)
Medicare guidelines for prosthetics
Medicare provides coverage for prosthetic devices that you need to replace or enhance your mobility, appearance, or bodily function. Before Medicare can help cover the prosthesis, your doctor must order them and they must be considered medically necessary. In some states, you may need prior authorization for a specific type of lower-limb prosthetic device before Medicare will cover it.
Types of prosthetics covered by Medicare
Medicare has extensive coverage of prosthetic devices. Medicare also covers some items, like eyeglasses or contact lenses under the prosthetic device category after a cataract operation. Other examples of prosthetic devices covered by Medicare include:
Breast prostheses
Surgical bras
Ostomy bags (medical device used to collect waste from the body after a surgical procedure)
Cochlear implants and other specific surgically implanted prosthetic devices
Urological supplies like an artificial urinary sphincter (used to treat severe urinary incontinence in men)
Because Original Medicare doesn’t cover dental care, prosthetic devices related to oral health aren’t covered. If you need dentures or dental implant coverage, you may want to look into a dental insurance plan or a Medicare Advantage plan.
Out-of-pocket costs for prosthetic devices under Medicare
You’ll pay 20% of the cost of the prosthetic device after you meet your Part B deductible. Prosthetic devices can be quite costly depending on what you need. Some prosthetic limbs can cost upwards of $50,000, so your coinsurance (share of the costs) could become expensive too. A Medicare Supplement plan can help reduce your out-of-pocket costs.
You must purchase the prosthetic device you need through a Medicare-enrolled supplier for coverage. Otherwise, you may have to pay more—or even the full cost of the equipment.
Does Medicare Advantage cover prosthetic devices?
Medicare Advantage plans cover the same services as Original Medicare, which means that they will also help pay for a prosthetic device. These private policies also often include additional benefits such as routine dental services, which could help you cover dentures, dental implants, and other prosthetic devices for oral care.
Keep in mind that Medicare Advantage plans vary widely in coverage and out-of-pocket costs. Check your summary of benefits to see how your plan covers prosthetic devices, and get in touch with your insurance carrier if you have questions about healthcare costs.
Medicare and prosthetics
Between finding a Medicare-enrolled supplier and understanding Medicare, your options for coverage can be confusing. Let a Medicare Advisor at Chapter help you understand your plan and how much you can expect to pay for the prosthesis you need. Contact us at 855-900-2427 or schedule an appointment to get answers to all your Medicare questions.