Medicare covers a variety of prosthetic devices when deemed medically necessary by a licensed healthcare provider, but costs and coverage can vary widely.
A prosthesis is a human-made substitute for a missing body part. The field of research that designs and builds prostheses is called prosthetics.
Examples of prostheses include a prosthetic arm, leg, or breast prosthesis. However, did you know that cochlear implants and eyeglasses can also be considered prosthetic devices?
Let’s do a deep dive into prosthetics and Medicare. We’ll discuss Medicare coverage of artificial limbs and other types of prostheses. We’ll first give you an overview of a patient’s criteria for receiving Medicare coverage for a prosthetic device. Then, we’ll go into the specifics of each common type of prosthesis.
Examples of prosthetic devices that Medicare may cover
Medicare may cover a prosthetic device needed to replace a body part or body function if a Medicare-enrolled healthcare provider orders them.
Examples of prosthetic devices that Medicare sometimes covers include:
- Artificial limbs
- Artificial eyes
- Eyeglasses or contact lenses after a cataract operation
- Breast prostheses
- Ostomy bags and certain related supplies and urological supplies
Some surgically implanted prosthetic devices, including cochlear implants
Generally, a prosthetic device is covered by Medicare Part B (medical insurance). Medicare Part B typically covers durable medical equipment (DME) that lasts for at least three to five years.
After you meet your Part B deductible, you’ll typically pay 20% of the Medicare-approved amount for prosthetic devices.
Now that we have given you a general overview let’s look at a few specific types of prostheses.
Does Medicare cover artificial limbs?
Prosthetic limbs must be custom fitted for each person. The materials and design may vary, which can cause the price to fluctuate significantly.
Medicare Part B covers artificial limbs when your Medicare-approved doctor orders them. To receive help with paying for a prosthetic leg, arm, or foot, you must use a Medicare-approved company that agrees to create the device for a certain amount.
You will pay 20% of the cost of the artificial limb.
Does Medicare cover artificial eyes?
You may be missing an eye due to a congenital condition. Or you may have lost your eye due to eye trauma or a medical condition such as cancer.
If your Medicare-approved doctor orders an artificial eye, Medicare Part B will pay for 80% of this prosthesis.
Does Medicare cover eyeglasses & contact lenses?
It’s important to note that Original Medicare (Medicare Part A & B) doesn’t usually cover eyeglasses or contact lenses. However, if you have cataract surgery, Medicare Part B may pay for contact lenses or one pair of eyeglasses with standard frames. (You must pay the additional costs if you want upgraded frames.)
You will be required to pay 20% of the Medicare-approved amount, and Medicare Part B will pay the rest (after you meet your deductible). Your eyeglass or contact lens supplier must be Medicare-approved.
Does Medicare cover breast prostheses?
Medicare Part B covers some external breast prostheses (including a post-surgical bra) after a mastectomy.
Part A (hospital insurance) covers surgically implanted breast prostheses after a mastectomy if the surgery takes place in an inpatient setting. (Part B may cover the surgery if it takes place in an outpatient setting.)
Expect to pay 20% of the Medicare-approved amount (on top of your Part B deductible) if your breast prosthesis is covered by Medicare Part B.
Medicare Part A has a $1,600 deductible per benefit period. Once you meet your deductible, you’ll pay $0 for the first 60 days of your inpatient hospital stay each benefit period.
Does Medicare cover ostomy supplies and urological supplies?
Have you had a colostomy, ileostomy, or urinary ostomy and are a member of the Medicare program? Medicare Part B covers 80% of the cost of medically necessary ostomy supplies.
Does Medicare cover cochlear implants?
Cochlear implants are surgically implanted devices that may help those who severely struggle to understand spoken words. A Medicare-approved doctor will determine your eligibility for cochlear implants. You may only have to pay 20% of the cost if they deem them a medical necessity.
What types of prosthetics are not covered by Medicare?
Medicare covers prosthetics deemed medically necessary by a doctor. Cosmetic prostheses are typically not covered, including dentures, dental implants, or cosmetic breast implants.
Paying for your portion of a prosthesis
Because some prostheses can be expensive, you must receive prior authorization from Medicare and understand your costs before you agree to a prosthetic device. Your cost is determined by where you receive services, whether you purchase the prosthetic device from a Medicare-approved facility, and other health insurance you may have.
For example, Medicare Advantage plans (sometimes called Medicare Part C) must cover all that Original Medicare covers. But such plans may also offer additional benefits, such as eyeglasses and dental visits.
Or you may consider a Medigap plan to help pay for your part of the costs when using Original Medicare. These plans don’t offer additional services like Part C plans. Instead, they pay most of your out-of-pocket costs when you have Original Medicare.
Reviewing your Medicare plan options is easy with our Find a Plan tool. Just enter your zip code to see the costs and benefits of Medicare plans in your area. Or, call us toll-free at 888-992-0738 and one of our licensed agents can answer your questions and help you choose the right coverage for your particular needs.