Medicare Coverage of Prosthetics and Orthotics
Medicare Part B (Medical Insurance) covers prosthetic devices needed to replace a body part or function when a doctor or other health care provider enrolled in Medicare orders them. Medicare Part B covers orthotic and prosthetic devices, including artificial limbs and eyes; braces for arm, leg, back, and neck; and breast prostheses and related supplies following a mastectomy.
Medicare Part B covers orthopedic shoes if they're a medically necessary part of a Medicare-covered orthotic leg brace. Prosthetic shoes are covered by Medicare Part B if they're an integral part of a prosthesis for patients with a partial foot amputation.
Prosthetic devices also include:
- One pair of conventional eyeglasses or contact lenses provided after a cataract operation.
Generally, Medicare doesn't cover eyeglasses or contact lenses. However, following cataract surgery that implants an intraocular lens, Medicare Part B (Medical Insurance) helps pay for corrective lenses (one pair of eyeglasses or one set of contact lenses). Medicare will only pay for contact lenses or eyeglasses provided by a supplier enrolled in Medicare, no matter who submits the claim (you or your supplier).
- Ostomy bags and certain related supplies: People with Medicare Part B who've had a colostomy, ileostomy, or urinary ostomy are covered.
- Urological supplies
- Breast prostheses (including a surgical bra) after a mastectomy: Medicare Part B (Medical Insurance) covers external breast prostheses (including a post-surgical bra) after a mastectomy.
Medicare Part A (Hospital Insurance) covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an inpatient setting. Part B covers the breast reconstruction surgery if it takes place in an outpatient setting.
- Cochlear implants and certain other surgically implanted prosthetic devices
All people with Part B are covered.
Your costs in Original Medicare
You must go to a supplier that's enrolled in Medicare for Medicare to pay for your device. You pay 20% of the Medicare-approved amount for external prosthetic devices, and the Part B deductible applies. Medicare will only pay for prosthetic items furnished by a supplier enrolled in Medicare, no matter who submits the claim (you or your supplier). Having an adequate Medicare Supplement plan will cover deductible and the 20% cost for prosthetic devices.
DMEPOS Competitive Bidding Program
Medicare’s Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program changes the amount Medicare pays for certain DMEPOS items. Under this program, suppliers submit bids to provide certain medical equipment and supplies to people with Medicare living in, or visiting, competitive bidding areas. Medicare uses these bids to set the amount it pays for each item. Qualified, accredited suppliers with winning bids are chosen as Medicare contract suppliers. The program:
Helps you and Medicare save money
Ensures that you continue to get quality products from accredited suppliers
Helps limit fraud and abuse in the Medicare Program
Original Medicare coverage for various types of orthotics
Your doctor may prescribe orthotic devices, or braces, to support weak joints or muscles. If you have foot pain or other health conditions involving your feet, your podiatrist or other provider might prescribe custom orthotics for your feet. Medicare Part B may cover orthotics in some situations.
People often think of orthotics as custom-made shoe inserts that can relieve foot pain. That’s a popular type of orthotic, but there are other types as well, such as back braces. Medicare counts them as durable medical equipment. Medicare Part B may cover orthotics if both of the following are true:
- Your Medicare doctor (or podiatrist) prescribes orthotics for you as medically necessary.
- You buy the orthotics from a Medicare-participating supplier.
Medicare Part B may also cover therapeutic shoes and inserts for people with diabetes who suffer from severe diabetic foot disease, if your Medicare-assigned doctor certifies that you need them. As with orthotics, these items must come from a Medicare-participating supplier.
According to the American Orthotic and Prosthetic Association (AOPA), the durable medical equipment regional carriers (DMERCs) have determined that the useful lifetime of orthotic devices is five years. Medicare will pay for a replacement during this five-year period only if the device is lost, irreparably damaged or the patient’s medical condition changes such that the device no longer meets the patients’ needs. Medicare coverage of replacement due to irreparable wear during the period of the device’s five-year useful lifetime is currently not covered. An AOPA government affairs representative explained that the four DMERCs define wear as deterioration sustained from day-to-day usage over time, where a specific event cannot be identified that caused the deterioration.
If a physician determines that a replacement device, or replacement part, is necessary: 1) such determination shall be controlling; and, 2) such replacement device or part shall be deemed to be reasonable and necessary; except that if the device, or part, being replaced is less than three years old (calculated from the date on which the beneficiary began to use the device or part), Medicare may also require confirmation of the necessity of the replacement device or replacement part.
Medicare classifies orthotics under the “Durable Medical Equipment Prosthetics, Orthotics, & Supplies (DMEPOS)” category. If you meet the conditions described above, Original Medicare generally pays 80 percent of the Medicare-approved cost for orthotics, therapeutic shoes, and shoe inserts after you have met your deductible; after that, you’ll only be responsible for the remaining 20 percent. As in most instances, a Medicare Supplement plan will cover the 20 percent financial exposure. Speak to a licensed Agent about the best Medigap plan for you.