The world of insurance coverage and funding sources can be difficult to navigate, particularly when someone is simultaneously dealing with a physical/emotional loss. There are resources available to assist in gaining and understanding coverage.

The most common questions that arise involve the coverage of prosthetic devices, which are custom fabricated and provided on a purchase basis only (not rental). The following are some insurance tips when dealing with private or government funding.

• There is a difference between coverage for internal and external prosthetic limb/joints. Artificial limbs are external prosthetic devices (EPA).
• Some insurance companies categorize external prosthetic limbs with durable medical equipment (DME).
• The insurance benefit and authorization requirements for external prosthetic limbs and durable medical equipment may vary, so it is important to distinguish between the two.
• Each major component of a prosthetic limb is associated with a code. HCPCS codes, Healthcare Common Procedure Coding System numbers, are the codes used by Medicare and monitored by CMS, the Centers for Medicare and Medicaid Services. They are based on the CPT codes (Current Procedural Technology codes) developed by the American Medical Association.
• In order to receive insurance benefit for replacement of any major prosthetic component, a physician prescription is typically required. This applies to replacement of socks, liners, sockets, prosthetic feet, knees, hands, etc…

When calling an insurance to obtain benefits for a particular service, it is important to:

• Ask the right questions
• Document the name of the insurance representative providing information
• Obtain a reference number for the call, when possible
• Call several times to ensure the correct information is provided

What are the right questions? To obtain the most accurate information, it is helpful to include as much information about the procedure as possible. For example, when calling for benefits for an external prosthetic limb, the particular HCPCS code should be provided. Since there are so many codes associated with a prosthesis, the main, or ‘base’, code may be provided. An amputee may obtain the HCPCS code information from the prosthetist he or she is working with.

Other necessary information for the procedure coverage would be:

• Co-pay amount
• Co-insurance amount (a percentage of the allowed charge)
• Deductible
• Is the deductible per calendar year or per plan year?
• Out of pocket maximum (the maximum amount a patient has to pay per year)
• What applies to the out of pocket maximum?
• Is there a benefit capitation for this procedure?
• Are there any limitations or exclusions for this type of procedure?
• Is there a pre-existing exclusion?
• If there is a pre-existing exclusion waiting period, when does it end?
• If there has been no lapse in coverage, does the pre-existing exclusion waiting period apply?
• Is pre-authorization/notification/certification required?
• Is the provider in network?
• If there are out of network benefits, what are those benefits?

Government Programs

Government programs receive federal or state funding to provide coverage for eligible persons to receive coverage for medical care. There are several programs in existence today to help those in need.

Medicare

The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation’s largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people age 65 or older, some eligible disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant). Part B Medicare covers 80% of the cost of prosthetic devices, after the Medicare deductible has been met.

For more information, go to www.Medicare.gov, or call 1-800-MEDICARE.

Medicaid

Medicaid provides Medical coverage to low income individuals and families. The state and federal government share the costs of the Medicaid program. Medicaid services in Florida are administered by the Agency for Healthcare Administration.

Medicaid eligibility in Florida is determined either by the Department of Children and Families (DCF) or the Social Security Administration (for SSI recipients).

DCF determines Medicaid eligibility for:

• Low income families with children
• Children only
• Pregnant women
• Non-citizens with medical emergencies
• Aged and/or disabled individuals not currently receiving Supplemental Security Income (SSI)

For more information on Florida Medicaid, go to http://www.dcf.state.fl.us, or call 1-866-762-2237.

Vocational Rehabilitation

Florida’s Vocational Rehabilitation program is a division of the Department of Education. Every state has such a program, which receives a combination of funding from the federal and state level. The goal of this program is to help persons with physical and/or mental challenges participate in the work force. There is a financial application and eligible persons may face a co-pay, based on their income. Applicants are prioritized based on the severity of their condition(s). Vocational Rehabilitation aims to provide eligible applicants with the ‘tools’ they need to do the following:

• Transition into the work force after a disabling injury
• Find new employment after a job loss
• Maintain current employment

The ‘tool’s required may also include an initial prosthesis, or prosthetic replacement.

To learn more, go to www.rehabworks.org, or call 1-800-451-4327.