Medicare and Prosthetics: Legs, Eyes, and Other Prosthesis Coverage
Key Takeaways
- 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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Are Prostheses Covered by Medicare?
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.
A Medicare Supplement plan (also called Medigap) from a private insurance carrier can help with the out-of-pocket costs that aren’t covered by Original Medicare. You’ll pay an additional monthly premium for Medigap coverage.
If you have a Medicare Advantage plan (where a private insurance company provides coverage to substitute for Original Medicare), it will cover prostheses as well. Medicare Advantage must at least match the coverage from Original Medicare and may provide additional benefits. To take full advantage of your insurance, you may need to get your prosthesis and related treatment through a doctor, equipment suppliers, and healthcare facilities that are in your plan’s provider network.
Keep in mind that you can’t enroll in both a Medicare Supplement plan and a Medicare Advantage plan, so carefully consider what options will best serve both your healthcare needs and your financial situation.
Can People with Limb Loss Get Medicare?
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.
Experiencing limb or eye loss does not necessarily mean you are disabled. 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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How Much Does Medicare Pay for a Prosthetic Leg?
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 must meet your Part B deductible for the year before your insurance starts to pay for services, including prostheses.
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 $70,000. 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.
Does Medicare Cover Artificial Eye?
Medicare Part B will cover a portion of the costs for an artificial eye.
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
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:
Comparison of Eye Prostheses
Prosthetic Implant
Also known as an artificial or glass eye, replaces an absent natural eye.
Costs
Can range from $1,500 to more than $8,000, depending upon eye features
Medicare Coverage
20% of the Medicare-approved amount
Scleral Shell
Prosthesis that can be worn over a damaged eye.
Costs
Can range from $1,500 to more than $8,000, depending upon the prosthesis materials
Medicare Coverage
20% of the Medicare-approved amount
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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.
How Often Does a Prosthetic Eye Need To Be Replaced?
Prosthetic eyes can require 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.
How do I find a Medicare-approved supplier for a prosthesis?
The doctor who wrote your prosthesis prescription may also recommend a prosthesis company that can help fit you for your new prosthesis.
What Medicare part pays if I require surgery to implant my prosthesis?
Are there prostheses that Medicare doesn't cover?
Sources
- The cost of a new limb can add up over a lifetime. HSS.edu.
- Lower limb prostheses. CMS.gov.
- Medicare’s role for people under age 65 with disabilities. KFF.org.
- National coverage determination (NCD) for scleral shell. CMS.gov.
- Ophthalmic prosthetic FAQs. D. Danz & Sons.
- Prosthetic devices. Medicare.gov.
- Prosthetic eye coverage. Medicare.gov.
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