Does Insurance Cover Artificial Limbs? 

Does Insurance Cover Artificial Limbs? 

When life requires a quick education in limb loss, where do you turn for sound advice.  As a life-long amputee, I have first hand experience navigating this journey.  So what are the real questions that you need to have answered before seeking a new limb?  

What is my Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) coverage? 

The answer is most likely, yes but…..  

  • Medicare and Medicaid typically cover prosthetic services
  • Most insurance companies follow similar guidelines
  • Check with your insurance helpdesk – Know your policy details re: DMEPOS coverage

Know your out-of-pocket expenses and plan limitations: 

If there is a deductible or spend down. A deductible or spend down is how much money you must spend before insurance begins to pay for covered products and services. Deductibles or spend downs usually reset at the beginning of the year. High deductibles usually mean lower monthly payments. Some deductibles can be over $15,000 per year. 

How much copay that must be paid for each service or device. Copays can be a flat fee for office visits or a percentage of the service and device. Copays also reset annually. Most straight Medicare plans without a secondary payer have a 20% copayment.   

Plan limitations can include services not covered.  All plans have limitations, such as what items are covered and the number of times a service can be rendered or time intervals for before a device can be replaced. Medicaid limits some prosthetic supplies to one per year or devices to one every five years.   

Network providers and out of network coverage. Network providers are contracted to a set fee schedule. Avoid out of network providers as coverage can be very limited or non-existent. If Medicare, always ask if the provider accepts Medicare assignment. Providers that accept Medicare assignment use a set fee schedule and cannot charge over that cost.  

Automotive and Worker’s Compensation claims that have been settled are not covered.    

Important factors that impact your care

Other factors that can impact your prosthetic care are if you have a secondary insurance, your physician’s prescription, clinical notes, your activity level or potential K level, out of pocket expenses and your willingness to be your own advocate.   

  • A secondary or supplemental insurance can reduce out of pocket costs for copays. 
  • Your physician’s prescription and clinical notes are key to prosthetic healthcare by corroborating your vocation, hobbies / advocation, activity level or potential, desire to ambulate, condition of residual limb, cognitive ability to use, care, clean and following instruction of volume management. 
  • Notify your provider if anything changes such as moving to a new address, phone number, insurance(s), going into a hospital or skilled nursing facility, medications or onset of other medical conditions, etc. 
  • Your ability and willingness to be proactive in your healthcare by advocating and being an active participant for yourself is the best determinate for a positive outcome.     

Call Anew Life Prosthetics and Orthotics at (313) 870-9610 or contact us online so we can help you navigate your insurance coverage and out of pocket expenses. Insurance companies make it difficult to get the care you need but Anew Life’s billing team can help you by verification of your insurance coverage, work with you to obtain required documents from your physician, submit prior authorizations, provide a prosthetic device designed and built for your needs, bill your insurance, and offer payment options that work for you.  

Leave a Reply