Some of the questions most frequently asked by amputees relate to the purchase of prosthetic devices, wheelchairs, ramps, and other adaptive equipment. Given the exorbitant costs of many of these devices, most amputees will require some financial assistance to obtain the equipment needed to maintain their independence.

Starting the process

Before attempting to find a funding source amputees should determine the specific assistive device they need and where to purchase it. For new amputees or those who need a new prosthesis, consulting with medical and rehabilitation professionals is an essential first step. Good record keeping is important so that you have accurate information on hand when it is requested.

Some funding sources require applicants to prepare a justification statement before funds are appropriated. They may require that applicants demonstrate that the service or technology will enhance their ability to prepare for, get, or keep a job, or that it will enhance their independence. Success in securing funding frequently depends on the applicant’s ability to address the specific agency’s unique requirements.

MEDICARE

In the U.S., Medicare is the largest financial resource for prosthetic care. In addition to prostheses, Medicare commonly covers wheel-chairs, walkers, and crutches. Ramps, adaptive driving devices, and other nonmedical devices are not covered.

Obtaining Social Security Disability

(SSD) Medicare coverage For those under age 65, the first major obstacle to obtaining Medicare coverage for assistive devices may be getting approval for SSD benefits. Approximately 70 to 75 percent of SSD applicants are denied initially. Persistence, detailed documentation of your medical history, and the help of an attorney are often the keys to getting approval.

L-Codes and Level II Modifiers

The “L-Code” system is the current method of billing Medicare for orthotic and prosthetic services. Historically, Medicare had no qualifying standards that related which components and procedures were appropriate for each amputation level. The recent introduction of Level II or “K-Modifiers” helped organize components and amputees’ access to them based on the patient’s rehabilitation potential as determined by the prosthetist and ordering physician. Criteria considered for assessing the functional level include the patient’s past history and current condition including the status of the residual limb, the nature of other medical problems, and the patient’s desire to ambulate.

Classification levels are:

K0 (Level 0) - Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.

K1 (Level 1) - Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator.

K2 (Level 2) - Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.

K3 (Level 3) - Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic use beyond simple locomotion.

K4 (Level 4) - Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete. Because of their greater rehabilitation potential, amputees in higher levels are generally allowed better choices of prosthetic components, while prostheses are denied as not medically necessary if the patient’s potential functional level is “O.” Exceptions are considered in individual cases if additional documentation is included that justifies the medical necessity.

If your claim is denied

If your Medicare claim is denied, it is important to understand why, and to find out what options you have left. Reasons for denial of claims for Durable Medical Equipment and prosthetic devices usually fall into five categories:

1. Lack of Medical Necessity
2. Noncovered Services – Medicare has excluded these items from its list of covered services.
3. Incomplete Information
4. Duplicate Submission - Claims denied for this reason should be investigated immediately.
5. Not Separately Payable - These claims were denied because the service was considered to be included in another code.

In some cases, appeals can be made; in others, they cannot. Your primary source of assistance with appeals and resubmission of denied claims will be your provider’s administrative staff. If you have questions about your eligibility for Medicare or want to apply for it, you should contact the Social Security Administration (1-800/772-1213).

MEDICAID

Medicaid is a jointly funded cooperative venture between the federal and state governments to assist states in the provision of adequate medical care to eligible, needy people. Within broad national guidelines that the federal government provides, each of the states:

1. Establishes its own eligibility standards
2. Determines the type, amount, duration, and scope of services
3. Sets the rate of payment for services
4. Administers its own program

Medicaid eligibility and covered services vary considerably from state to state, as well as within each state. Unfortunately, coverage for prosthetic care is not mandated; therefore, it ranges from reasonably good to nonexistent.

To be eligible for federal funds, states must provide Medicaid coverage for most individuals who receive federally assisted income-maintenance payments, as well as for related groups not receiving cash payments. Some examples of the mandatory Medicaid eligibility groups are low-income families with children, Supplemental Security Income (SSI) recipients, and infants born to Medicaid-eligible pregnant women.

For people with too much income to meet the mandatory eligibility requirements and/or those adopted by their state, many states have a “medically needy” program. This option allows them to “spend down” to Medicaid eligibility by incurring medical and/or remedial care expenses to offset their excess income or by paying monthly premiums to the state equal to the difference between family income and the eligibility standard.

For information about your state’s version of the Medicaid program, contact its administering agency, usually the Department of Health and Human Services, or Department of Medical Assistance. Most of your healthcare costs are covered if you have Medicare and you qualify for Medicaid. States also have programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain low-income people.

Prescription drug assistance programs are also available. These programs offer discounts or free medications to individuals in need. For more information on these programs, call your nearest medical assistance office listed in the telephone book under Medicaid, Social Services, Medical Assistance, Human Services or Community Service.

VETERANS ADMINISTRATION

The Veterans Health Administration (VHA) provides a broad spectrum of rehabilitative care to its beneficiaries, including a wide array of prostheses, mobility devices such as wheelchairs, and adaptive driving equipment. In addition to coverage for veterans, the VA provides needed healthcare benefits, including prosthetics, medical equipment, and supplies, to certain children of Vietnam veterans. Veterans may also receive VA healthcare benefits, including prosthetics and medical equipment through participation in the VA’s vocational rehabilitation program.

VA healthcare enrollment is a new system providing access to a comprehensive package of services. To be eligible for healthcare enrollment, you must have:

• Been discharged from active military service under honorable conditions
• Served a minimum of two years if discharged after September 7, 1980 (prior to this date there is no time limit)
• If a National Guardsman or Reservist, served the entire period for which you were called to active duty other than for training purposes only

Artificial limbs must be prescribed by a designated physician/podiatrist of the VA’s Amputee Clinic Team or the Prosthetic Representative. Devices may then be fabricated and fitted by VA hospitals or clinics, private prosthetic facilities on contract with the VA or, under certain circumstances, by noncontract prosthetists. While the VA prefers that patients use either VA facilities or private facilities under contract with the VA, veterans who have previously received artificial limbs from commercial sources may continue to receive services from their noncontract prosthetist, providing the prosthetist will accept the VA preferred provider rate for the geographic area. Veterans may also receive services from noncontract vendors when a prescribed limb or component is not available through VA or contract facilities.

For more information you can visit the VHA Web site at www.va.gov/About_VA/Orgs/VHA/index.htm or call the VA Health Benefits Service Center toll-free at 1-877/222-VETS.

CHAMPUS/TRICARE

CHAMPUS (Civilian Health and Medical Programs of the Uniformed Services), now called TRICARE Standard, has evolved into a key component of the new TRICARE health benefits program of the Department of Defense. Any of the TRICARE programs are available to dependents of active-duty service members and retirees and their families and survivors. Eligible family members include spouses, unmarried children under age 21, unmarried children who are full-time students under age 23, and stepchildren adopted by the sponsor.

For more information regarding any of the TRICARE programs, contact your TRICARE Service Center or visit the military’s TRICARE Web site at www.tricare.osd.mil/ or Palmetto Government Benefits Administrators’ TRICARE Web site at www.mytricare.com/

VOCATIONAL REHABILITATION

Most states have vocational rehabilitation programs to help people with limb loss obtain and keep employment. These programs vary widely from state to state as to the eligibility requirements and services provided. Some may fund prosthetic care and other assistive devices if they are deemed necessary for employment or job performance. Assistive devices, such as wheelchairs, lifts, and adaptive driving equipment are often furnished to enable a person to get to the job site.

Visit www.pueblo.gsa.gov/crh/vocational.htm for contact information and links to your state vocational rehabilitation agency’s Web site.

STATE TECHNOLOGY ASSISTANCE PROGRAMS

These programs support statewide, comprehensive, technology-related assistance for individuals of all ages with disabilities. State projects typically provide assistance in choosing and acquiring off-the- shelf, modified, or customized items and equipment used to increase, maintain, or improve functional capabilities of individuals with disabilities.

A few state programs provide direct financial assistance to individuals in need of various types of adaptive equipment, including prostheses. Some have loan programs. Others provide no funding at all to individuals. Most do have information and referral services and may be able to direct you to local sources of financial assistance.

The telephone number for your state’s program may be found in the “blue pages” of your local directory. A listing of state assistive technology projects, complete with contact information and links to Web sites, may be found on the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) Web site at www.resna.org/taproject/at/statecontacts.html

PRIVATE INSURANCE

Coverage for prosthetic care and durable medical equipment varies widely from one insurance company to another and may also differ with various policies offered by a given company.

Coverage can range from all medically necessary devices for life to no coverage at all. While it is impossible to provide specific information about every health insurance company, there are some basic things to consider when selecting an insurance policy:

• Eligibility requirements
• Pre-existing condition clauses
• Devices covered (Get something in writing to assure that artificial limbs are covered.)
• Coverage limits
• Limits on number of items per year or per lifetime
• Rate of payment (Should be at least comparable to Medicare rates.)
• Preferred Provider Network (Is your current prosthetist included?)
• Must you go through a “gatekeeper” to obtain care?

Many health insurance companies have Web sites through which you may be able to obtain information about their policies. In addition, there are several Web sites that inform consumers and help them compare health insurance companies and policies. They include: www.insure.com/health/, www.insweb.com/, www.netquote.com/, and www.quotesmith.com/#medical/

Insurance problems

If you have problems getting the coverage to which you are entitled from your insurance company, the most valuable source of assistance is your state department of insurance. This office is located in the capital city of each state and the telephone number should be in the “blue pages” of your local directory. Insurance commissioners can take action against insurance companies, agents, and brokers. They are empowered to conduct investigations, acquire records of relevance to your case, issue orders, hold hearings, and suspend and revoke licenses. Contact information may also be found on insure.com’s state gateway page at www.insure.com/states/ index.html/

MEDICAL DISCOUNT PROGRAMS

Relatively new on the healthcare scene are medical discount programs. These companies negotiate with PPO providers for their members to receive discounts on medical goods and services ranging from prescription drugs to office visits to nursing home care. While durable medical equipment is often included in the benefits packages provided in the programs, prosthetic care is not usually specifically mentioned.

The programs’ advantages to the providers are immediate payment, less paperwork, and no “red tape” in getting approval for services provided.

Advantages to the patient are discounted medical fees, no deductibles, no pre-existing condition clauses, unlimited use of services, no claim forms to fill out, and relatively low “premiums” or fees.

Most of the companies stress that this is not insurance and should not replace existing insurance. However, for those who are uninsurable or cannot afford insurance coverage, this may be an alternative worth investigating. Since all of these companies are relatively new and have not established an extensive track record, it would be wise to thoroughly check out any company before making a commitment. Read all the fine print, make sure all your questions are answered to your satisfaction, and consider consulting the Better Business Bureau to see if complaints have been registered.

Examples of medical discount programs currently available are:

POWERx Medical Benefits Network
www.powerx.net//
800/421-4943

HealthCove
www.healthcove.com/
800/796-5558

Care Entrée
www.careentree.com/
800/820-6474

All of these sources can help you begin locating funding for your needs. If you need additional assistance or information, please contact the Amputee Coalition of America toll-free at 1-888/ AMP-KNOW (267-5669).

© Amputee Coalition of America. Local reproduction for use by ACA constituents is permitted as long as this copyright information is included. Organizations or individuals wishing to reprint this article in other publications, including other World Wide Web sites must contact the Amputee Coalition of America for permission to do so.