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Bill May Improve Access to Orthotics, Prosthetics in Medicare

Are orthotics (artificial supports for one’s spine and/or limbs) and prosthetics (artificial body parts) covered by Medicare? For the most part, the answer is yes. But bipartisan legislation has been re-introduced this week to improve standards for orthotics and prosthetics for Medicare coverage. This may guarantee access to better value and quality of such medical equipment as prosthetic limbs for those who are eligible under Medicare, while also reducing fraud.

What the Bill Says about Medicare Coverage

Senator Chuck Grassley (R-Iowa) and Senator Mark Warner (D-Virginia) (both members of the Senate Finance Committee that recently advanced The CHRONIC Care Act of 2017) have re-introduced The Medicare Orthotics and Prosthetics Improvement Act of 2017.  According to a statement released by Senator Grassley, the bill would “apply accreditation and licensure requirements to providers and suppliers for Medicare payment purposes,” as well as “modify the designation of accreditation organizations for orthotics and prosthetics to recognize orthotics and prosthetics suppliers as independent professional providers of medical care for Medicare beneficiaries.”

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What an Orthopedic Surgeon Says about the Bill

To help break through the legal speak, we asked Dr. Christopher Cassels an orthopedic surgeon in Maryland with more than 40 years experience, what this may mean for Medicare recipients who may need to acquire prosthetics or orthotics.

“The airwaves (TV, internet and radio) are replete with advertisements promoting devices which purport to improve the quality of life, treat, and even cure medical conditions. Most of these claims have very little basis in fact,” he said. “Many, if not most, of the devices offered as therapeutic can be obtained in some form or another over the counter. It appears that this bill would serve to accredit and qualify certain providers in respect to prescribing and providing Medicare patients with prosthetics and orthotics. It would further help to assure that devices are prescribed for medically appropriate reasons and properly fitted to the individual patient.

“Particular attention would be needed to properly identify and credential providers and assure that all providers are properly trained in the prescribing and fitting of medical devices,” he continued. “In my opinion, orthotic and prosthetic devices should be covered by Medicare for those patients who have congenital, acquired or traumatic deformities or are in need of structural support. Such devices should be prescribed in order to improve function, mobility and quality of life. In some cases, such as facial disfigurement and breast surgery, coverage should extend to those in need of cosmetic support. The overall effect of improving a quality of life would be to reduce the number of visits to medical facilities and the need for medications, and perhaps even long-term care.

“There are continued advances in improving upon the weight, efficiency and approximation of normal anatomic structures,” he added. “Unfortunately, some of these advances are costly and offer little improvement over more ‘tried and true’ devices. There are providers who would prescribe these devices because of all the ‘bells and whistles’ promoted by the manufacturers when in fact there would be little functional improvement in the device.”

What Medicare Currently Covers for Prosthetics, Orthotics

Currently under Medicare Part B, beneficiaries are covered for prosthetic devices when called for by a doctor as a necessity to replace a body part or important function. According to Medicare.gov, prosthetic devices that are covered include:

  • Breast prostheses (including a surgical bra) after a mastectomy
  • Cochlear implants and certain other surgically implanted prosthetic devices
  • One pair of conventional eyeglasses or contact lenses provided after a cataract operation
  • Ostomy bags and certain related supplies
  • Urological supplies

In addition, orthotic devices that are covered under Medicare Part B include:

  • Orthotics provided by a supplier that’s enrolled in Medicare
  • Artificial limbs and eyes
  • Arm, leg, back, and neck braces
  • Orthopedic shoes only when they’re a necessary part of a leg brace

Make sure you check with your healthcare provider to ensure they are enrolled and participating in Medicare before buying prosthetics or orthotics, though. Patients pay 20% of the cost for the device, and the Medicare Part B deductible applies, but only when the doctor and supplier of the equipment are enrolled and participating in Medicare as well. When suppliers are enrolled but are not participating, they may not accept the assignment of the medical device, which means they can charge you as much as they want. The location and type of facility where you receive the device, in addition to your doctor’s assignment and charges, will also affect how much you pay.

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