Millions of Americans need artificial body parts to lead active lives. Most health plans pay at least some of the related costs, but that's not the whole story. Here's all you need to know about how insurance covers prosthetic devices.
It's hard to say how many Americans use prosthetic devices like artificial arms or legs.
The Amputee Coalition, for example, estimates about 185,000 people in the U.S. have limbs amputated each year and suggests many of those limbs are replaced by prostheses. But that statistic doesn't account for people born with partial limbs, or with no limbs at all.
Speaking of which, the U.S. Centers for Disease Control and Prevention (CDC) says around 2,250 babies are born in the U.S. each year with missing or smaller-than-normal limbs. Not all of those children need prosthetic devices, of course, but many do.
As surprising as those stats may be, they're still only part of the story. That's because there's more to prosthetics than artificial hands, arms, and legs.
Artificial eyes, ears, teeth, and facial bones are prosthetic devices, too. As are replacement hip, knee, and elbow joints.
Even if you're just talking about removable prostheses, arms and legs aren't the extent of what's available to people who need such assistance. Women who have mastectomies often use prosthetic breast forms after surgery, for instance.
At any rate, it's safe to say millions of Americans currently rely on artificial body parts to lead active lives.
The question is: does health insurance help pay for those artificial body parts? Actually, it usually does--and that's true whether you're talking about coverage you get through an employer or coverage you get elsewhere, such as directly from an insurance company, from the federal or state exchanges, or from Medicare or Medicaid.
Before we tackle how each of those forms of health insurance cover (or don't cover) prosthetic devices, let's talk about one of the main reasons--besides medical necessity--that coverage is so important.
The reason, of course, is cost. As in, artificial body parts are expensive.
Even a cosmesis, or a prosthesis that's designed mainly for looks and that has little or no functional use, usually costs between $3,000 and $5,000.
A prosthetic arm with a split hook at the end, on the other hand, costs as much as $10,000. A myoelectric, or computer-controlled, arm that's both more realistic and more functional often costs $30,000 or more.
Artificial legs tend to be pricey, too. It isn't unusual for an advanced device that replaces a person's leg above the knee to cost upwards of $50,000.
Prosthetic breast forms may be the most affordable of the bunch, but even they cost as much as $500.
In other words, health insurance can, and often does, play a vitally important role in helping people in need afford these and other prostheses.
Generally speaking, if you have health insurance of some sort, it should cover at least a portion of the costs associated with the prosthetic devices you need.
Don't take that to mean all plans pay for all prostheses, however. Different types of health insurance cover them in different ways and in different amounts.
Here are some specific details related to how employer-sponsored, Obamacare (or "marketplace"), Medicare, Medicaid, and other kinds of coverage deal with prosthetics.
There isn't a whole lot to say about how employer-sponsored or job-based health plans treat prostheses other than this: most of these plans cover these devices to a certain extent.
That's especially true if you work for a fairly small company. How so? As a result of the Affordable Care Act (also known as the ACA or Obamacare), all individual and "small group" health insurance plans must now cover something called Essential Health Benefits, or EHBs.
Included among the 10 categories of services that make up these EHBs are rehabilitative and habilitative services and devices. Doesn't mean much on its own, I know. Thankfully, healthcare.gov specifies that these are "services and devices to help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills."
Basically, that means all individual and most small-group plans--or plans provided by employers with 50 or fewer employees--have to cover prosthetics in some way.
What if you work for a large employer? The ACA doesn't impact them, which means they don't have to cover prosthetics or other devices or services tied to these EHBs. Most still do, though.
As is so often the case with health insurance, how fully the coverage you get through an employer pays for artificial body parts depends on the company, the plan, and a number of other factors.
Some plans pay for everything as long as it's considered medically necessary and after you've met your deductible or covered your copay or co-insurance. Others put limits on how much of the bill they'll pick up. Or they'll limit how often you can replace damaged or defective devices.
Only plans that cover the EHBs mentioned above can be sold via the federal or state health insurance exchanges or marketplace.
As such, all marketplace plans cover prostheses in some way.
The federal government doesn't mandate how much coverage they provide, though, so don't shop for a marketplace health plan assuming they'll all cover prosthetic devices to the same extent.
If it's important to you that a marketplace or exchange plan pays for artificial limbs or other body parts, do your research. Read the fine print. Ask questions. Shop around and compare policies before you enroll in one.
Although a lot of Americans who don't get health insurance through an employer--and don't qualify for Medicare or Medicaid--get it through the marketplace, some get it elsewhere.
Specifically, they get health coverage directly from an insurance company. Or they get it through an independent agent or broker.
Even though these plans aren't being sold via the marketplace, the Affordable Care Act still requires them to cover the EHBs mentioned earlier. Which of course means they have to cover prostheses--at least to a point.
So, again, if you want off-marketplace health insurance that will pay for prosthetics, do your homework. Take a good look at any plan you think you might buy. And don't be shy about asking for clarification if the documentation you review doesn't make it clear how a policy deals with these devices.
Are you on Medicare? You're in luck if you need an artificial limb or other body part. That is, you're in luck if your physician or healthcare provider says one is medically necessary.
There are a few catches related to when Medicare covers the cost of a prosthesis, or how much of the cost it'll cover. According to medicare.gov, you must:
That site also specifies that how much you pay for a prosthetic device under Medicare depends on several things, including:
Want to learn more about Medicare and what it covers and doesn't cover? Read our "Ultimate Guide to Medicare."
First, some bad news regarding Medicaid and prostheses. The federal government considers prosthetic devices to be an "optional benefit" as far as this program is concerned.
Now for a bit of good news. If you live in a state that has expanded its Medicaid program, it has to cover the EHBs mentioned earlier. This means it has to cover prostheses in some form or fashion.
Also, if you need an artificial body part because of a disability, Medicaid has to cover it if a physician or healthcare provider says it's medically necessary.
Other than that, according to the Kaiser Family Foundation, every state offers prosthesis coverage as a Medicaid benefit even though doing so is optional.
These Medicaid programs don't all cover prosthetic devices in the same way or to the same extent. The best way to see how your state handles this kind of coverage is to contact your local agency and ask about it.
Just because a health insurance plan covers prosthetic devices, that doesn't mean it covers all such devices equally.
For example, some plans don't cover cosmetic prostheses. (They'll only pay for functional ones.) Others don't cover special prosthetic devices used for athletics. And some don't cover newer, more technologically advanced ones that often cost a lot more money than standard ones.
Something else to keep in mind as you shop for insurance or review your current plan: there's usually more to needing a prosthesis than the device itself. To begin with, many people require physical and occupational therapy after getting an artificial body part. Does your policy cover any of that? If not, those costs can quickly add up. (For more on whether or not your plan will pay for this kind of care, check out our article, "Does My Health Insurance Cover Physical Therapy?")
The same is true of any psychological therapy or counseling you may need as a result of your prosthesis.
Also, does your plan cover liners, sleeves, or socks?
And then there's the fact that many people who use prosthetic limbs have more than one, which they switch out depending on the situation. Will your current coverage, or the coverage you're considering, allow for that? Also, how does it deal with replacements--no matter how many prosthetic limbs you own?
Finally, how does your plan, or the insurer that provides it, define prosthesis? Does that definition include internal devices, or ones that have been implanted? Does it include things like breast forms? Or is it limited to what most of us think of when we hear the word, which is artificial hands, arms, legs, and feet?
How you answer these questions can make a big difference in your experience as a person with a prosthetic device.
A: Artificial limbs can cost anywhere from $2,000 or $3,000 to $100,000. Where your device falls in that range depends on a number of factors, one of which is how technologically advanced it is or isn't. For instance, myoelectric, or computer-controlled, prosthetic arms tend to cost upwards of $20,000, while myoelectric legs can cost $50,000 or more.
A: Prostheses can last anywhere from a few months to a few years, though three years seems to be the average. How long one lasts often depends on:
A: If you're talking about the Affordable Care Act or the ACA, yes, it covers these devices. If you're talking about health insurance plans sold through the marketplace or exchanges created as a result of the ACA, the answer is yes, too. All marketplace health plans must cover prostheses in some way. To learn more about this, read the "Employer Plan" section above.
A: Yes, Medicare Part B, in particular, helps pay for the cost of these devices as long as a physician or care provider says they're medically necessary.
A: Although the federal government doesn't require them to do so, every state Medicaid program currently covers prostheses to some extent. Contact your local Medicaid agency for specific details about its prosthetic coverage.
A: There are a number of organizations, many of them non-profits, which assist Americans in need. Some provide financial assistance. Others actually provide free artificial limbs or devices. For more information, visit amputee-coalition.org.
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