Health insurance coverage for prosthetic devices in the United States can create confusion due to complex regulations and payout policies. According to the World Health Organization’s Standards for Orthotics and Prosthetics Services, people who are in need of prosthetic devices and services should be able to have access “without suffering financial hardship.” This is true even for devices that are considered expensive or sophisticated. For many people both in the United States and internationally, this world standard is not yet possible.
Will Insurance Cover Your Desired Prosthesis?
Most Americans are aware of the murky, often unaccommodating nature of dealing with health insurance. Some personal accounts of individuals who have tried to acquire advanced prosthetics through insurance describe the emotional appeals process and impossible out-of-pocket costs, multiple airplane trips paid out of pocket to prosthetists all over the country, and having to first be fit with a basic, body-powered, hook-like device before being considered for an electric prosthesis.
In order to even be eligible through a major insurance provider for an upper limb prosthesis, the prescription process requires a medical practitioner to justify that the device is “medically necessary.” This requirement can create a barrier to access. “Medically necessary” is a blanket term, interpreted differently by each insurance system.
Within American health insurance systems, the definition of “medically necessary” is quite basic and covers very little. Most times this results in the prescription of simple, body-powered, hook-style arms. In order to receive an electric prosthesis, it needs to be proven that a body-powered device is not meeting the medically necessary requirements. The majority of upper limb prosthetic devices are denied, appealed, and denied again. This is especially true if the prosthesis provides more than just basic function.
This isn’t just an American problem. Canada, for example, is a country with universal healthcare. Prosthesis costs might be covered if the device allows a person to have “basic functionality.” But the guidelines for “basic functionality” can mean anything from the basic activities of daily living, such as eating and dressing, to participation in physically demanding manual labor to maintain employment. And each individual province has its own coverage guidelines.
What Will Your Prosthesis Cost?
In the United States, CMS/Medicare established the rules, regulations, and coding system clinicians use to describe and pay for the prosthesis being provided. Third party insurance companies in turn use these codes to establish their own set of guidelines. Medicare guidelines define the useful lifetime of a prosthesis and the services one is permitted to receive. There are limitations on coverage and high out-of-pocket costs depending on the cost of the technology being provided.
In addition, most insurances require you to meet an annual deductible. This deductible varies from policy to policy and the plan you chose for your coverage. Medicare’s deductible is around $200. Then, you are responsible for 20 percent of the Medicare-approved cost amount of the prosthetic device. This amount can vary tremendously. Advanced upper limb myoelectric prostheses can range from $40,000 to over $100,000.
The barriers to care and access for prosthetics are so pronounced in America that a large-scale analytical study is being proposed by the government. The Access to Assistive Technology and Devices for Americans Study will sort through major insurance systems’ coverage and denial policies for prosthetics and how this impacts clients’ needs and outcomes. This issue affects so many Americans with limb differences that the Amputee Coalition has a link on its website with letter templates directed to legislators and CEOs of each major insurance company to speak out against the lengthy and complex appeals and denials process.
A New Option
Unlimited Tomorrow has created a entirely new option with the first-ever direct-to-patient model for prosthetics. For the first time, you have a choice. TrueLimb can be purchased through your clinician, or directly from us – the choice is yours.