How Much of My Prosthetic Will Insurance Cover?

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How Much of My Prosthetic Will Insurance Cover?

Lower limb amputations have been fairly consistent over the last few decades. Researchers even expect that number to increase over the next few years. In fact, limb loss statistics show that:

  • More than 185,000 people undergo an amputation each year, which means 300-500 every day.
  • Roughly 2.1 million Americans live with lost limbs, and this number will likely double by 2050.
  • Those with limb loss spend over $500,000 in lifetime healthcare costs compared to nearly $365,000 for those without it.

These numbers lead many patients to wonder, “How much of my prosthetic will insurance cover?” If you’ve wondered the same, check out this brief guide on how much prosthetics cost, how much of it insurance could cover, what types of financial aid could help with the cost, and how Horton’s can help along the way.

How much do prosthetics cost?

The cost of the entire procedure depends on the situation. For example, was your limb amputated because of an accident? Did you have to amputate it due to a medical condition? All of these questions factor in to your overall cost and matter to insurance as well.

But when it comes to the cost of the actual limb, certain factors affect the price the most. These include:

  • The level of the amputation. This is because larger or more significant amputations mean a higher cost.
  • The patient’s level of activity. This is because more mobility requires more investment.
  • The technology used to make the device. This is because more durable materials will cost you more.

How much of my prosthetic will insurance cover?

Just as the prosthetic cost depends on your situation, insurance coverage depends on your coverage. Overall, however, most insurance plans cover prosthetics to a certain degree. However, many won’t cover the entire bill. That’s why it’s important to fully understand your insurance plan so that you can know how much they’ll cover and how much you’ll need to cover yourself. Keep in mind, all types of insurance require a doctor’s visit within the last 6 months.

Here are some of the more popular insurance plans and what they cover for you.

1. Employer-sponsored insurance

Those insured through their employers could see a higher percentage of the bill covered by the insurance plan. However, you must also meet your deductible and/or copay, depending on your insurance plan. According to the Affordable Care Act (ACA), small group insurance plans cover the Essential Health Benefits, and this includes prosthetics.

Even if you work for a large corporation, you might find that their insurance plan offers coverage for prosthetic limbs. However, you should be aware that the law doesn’t require them to do so.

2. Marketplace insurance

Marketplace insurance is fairly similar to employer-sponsored group insurance. It also has to cover the Essential Benefits, which include prosthetic devices. On the other hand, marketplace insurance varies a lot.

If you’re looking for good insurance, you need to look at a couple of options before choosing one. Look closely at what the coverage includes. Some insurance plans will only cover a prosthetic device if a medical professional considers it necessary.

3. Medicare insurance

Medicare coverage depends on your doctor’s recommendations. Both the doctor and the artificial limb supplier need to be enrolled in the program to get your prosthetic. The program uses the so-called K Level to determine the type of prosthesis for coverage.

This is a system that the U.S. Centers for Medicare & Medicaid Services (CMS) uses to figure out whether or not a prosthetic device is medically necessary for the patient.

4. Medicaid health coverage

Medicaid provides coverage for specific devices, but it varies from state to state. That’s why you need to check your local laws, and see if you have Medicaid coverage for your prosthetic.

The coverage is based on your medical necessities, but there are some limits to the size and type of prosthetic limbs that it covers. To make the most out of Medicaid, you need to work closely with your prosthetic care provider to find the right kind of prosthesis for you.

Other types of financial aid for prosthetics

Besides the traditional options, you have a few other types of financial aid that will allow you to cover the cost of prosthetic limbs. However, if your health insurance doesn’t cover your prosthetic device’s costs or will only cover it partially, you can get help from an assistance program.

Some of the most widely used programs include the:

As you can see, if you’re a veteran or a former athlete, there’s a chance that you’ll get financial aid with the help of an organization formed by people in the same profession and situation.

If you’re not a veteran or a former athlete, you can also cover the costs of a prosthesis through a healthcare credit card, such as CareCredit. CareCredit is a versatile option that includes financing for everything from dentistry and cosmetic services to medical equipment and weight loss surgery.

For more information

From the start, insurance coverage for your prosthetic depends on your situation and type of insurance. At Horton’s, our team will help you research your insurance benefits and will help you find a solution based on your coverage and personal needs.

We firmly believe that every patient requires this individualized prosthetic care approach. Our experienced prosthetists and staff will meet with you and answer any questions you have.

Keep in mind that the sooner you call and schedule an appointment, the more time you’ll be able to find resources that fit your circumstances. Contact us today at (501) 683-8889, or submit this form to request an appointment. We look forward to working with you and supporting you on your journey to better health.