How Much of My Prosthesis Will Be Covered by Insurance?

18 January 2022

Many Americans have dealt with the loss of a limb in their life. In fact, according to the Amputee Coalition, 2.1 million people in the U.S. are living with a lost limb, and 507 people lose a limb every single day.

The trauma of undergoing the loss of a limb is often just the beginning of the struggle for most people, especially when you consider the financial burden of paying for a prosthesis. The average lifetime healthcare costs of people who have lost a limb are more than $500,000, compared to around $361,000 for those who have not lost one.

You may find yourself wondering, “Does insurance cover prosthetics?” and asking how much you’ll have to pay out of pocket for a prosthetic arm, leg, or finger. Below, we’ll talk about prosthetics and insurance and answer our most frequently asked questions.

How Much Do Prosthetic Limbs Cost?

The cost of prosthetic limbs can range substantially from $2,000 to over $50,000, depending on the body part and the type of prosthesis it is. Prosthetic limbs also need to be replaced every two to four years. For specifics, how much does a prosthetic leg cost? Around $50,000 for a more advanced and over-the-knee model. And how much do prosthetic fingers cost? Even these have a high price tag, with a range of $5,000 to $75,000 depending on the features of the prosthesis.

Are Prosthetics Covered by Insurance?

The short answer is that yes, usually, most health insurance providers will cover part of the cost of prosthetic limbs. Insurance coverage is important for the obvious reason – medical necessity – and for the sheer cost of artificial limbs. Just like the cost of the limb, the amount of insurance coverage you have will depend on a few different factors, like your insurance company and plan.

Below, we’ll go over some of the most popular types of insurance and what they typically cover:

1) Employer-Sponsored Insurance

If your health insurance coverage comes from an employer-sponsored plan, you will most likely get a higher percentage of your prosthetic needs covered. Under the Affordable Care Act, even small group insurance coverage still needs to cover Essential Health Benefits, and luckily, this includes prosthetic limbs. The stipulation is that you still need to meet your deductible and co-pay.

2) Marketplace Insurance

Insurance purchased through the marketplace is similar to insurance that’s employee-sponsored. It also must cover Essential Health Benefits, which include prosthetic limbs. One issue that can arise with marketplace insurance is that there’s a wide variance in what’s offered, and it can be difficult to sort through all the plans to determine which one is going to have the best coverage for you without working with an agent.

3) Medicare

Medicare insurance is federal insurance coverage provided for U.S. citizens 65 or older or under 65 if you have a disability. Medicare isn’t determined by income. The coverage depends on your doctor and where you get your artificial limb from, and both need to be enrolled in Medicare coverage for you to get coverage. Your coverage will also depend on your doctor’s recommendation and if the prosthesis is deemed medically necessary. Medicare uses a system set by the U.S. Centers for Medicare & Medicaid Services (CMS) to determine the necessity and the type of prosthesis you’re eligible for.

4) Medicaid

Medicaid insurance is a federal and state-funded program that provides health insurance for low-income individuals and families, and it usually includes more benefits than Medicare does. The coverage for prosthetic limbs varies from state to state. As with Medicare, the coverage is conditional and based upon what your doctor and prosthetic care provider deem medically necessary.

5) Financial Aid Options

Outside of insurance, federal financial aid options are available. The most used programs are:

So, are prosthetics covered by insurance? We wish we could simply say, “Yes, 100% covered,” but unfortunately, the answer isn’t that simple. The good news is that at least part of your prosthesis will be covered, and there’s aid available to help split the difference if needed.

Navigating insurance and finding the best prosthesis for you can be challenging, so contact us today. Let’s work together to maximize your coverage and get the best artificial limb for you.