Some of the questions most frequently asked by amputees relate to the payment coverage for the costs of prosthetic fitting and associated services, and durable medical equipment (DME) such as wheelchairs, ramps and other adaptive equipment. The prosthetic fitting process can be very costly. Many durable medical devices such as sophisticated electronic wheelchairs are also expensive, and many people can experience financial hardship when trying to obtain these and other equipment needed to maintain their independence. This fact sheet will assist you in obtaining financial assistance for these devices that are essential to your day-to-day living.
For additional information and assistance, please contact the Amputee Coalition’s Resource Center at 888/267-5669.
1. How do I prepare to apply for assistance?
Before attempting to find a funding source, you should take these three steps:
- Determine what assistive device(s) you will need. Those seeking to replace old or outdated equipment such as wheelchairs or crutches need to determine the specific item needed (make, model, manufacturer, etc.) and from where it will be purchased. If there are changes in your disability or ability levels, consult with a therapist, physician or rehabilitation professional to determine the necessary features to accommodate you. For those who are recent amputees or in need of new prostheses, consulting with medical and rehabilitation professionals is the essential first step in the process.
- Get a prescription for the device(s) you have chosen.
- Gather personal information. No matter where you seek assistance, organized information is important. To help you avoid frustration and unnecessary delays, keep the following documentation updated and handy:
- Primary disability (time of onset and cause of disability)
- Secondary disability (time of onset and cause of secondary disability)
- Employment history
- Family gross income
- Monthly expenses (rent or mortgage payments, utilities, loans and bills, medical expenses, etc.)
- Health insurance information
- Name, age and relationship of dependents
Once you’ve accomplished the above steps, take time to consider how you want to justify your request for financial assistance. Some funding sources, particularly government programs, require the applicant to prepare a justification statement before funds are actually appropriated. State vocational rehabilitation agencies normally require that applicants demonstrate how the service or technology will enhance their ability to prepare for, get, or keep a job. If employment is not an expected outcome for you, then the justification statement must show that the device will enhance your independence. Other funding sources will have their own specific requirements.
2. Where can I find Financial Assistance?
Success in securing funding frequently depends on the applicant’s ability to address each agency’s unique requirements. Sources of financial assistance range from Medicare and other insurance options to national and local nonprofit organizations. The following is an overview of some of the available resources.
|State and Federally Funded Sources of Financial Assistance|
|If you are on Medicare, you can click here to see if the device you need is covered.Visit medicare.gov/coverage/orthotics-and-artificial-limbs.html for more information on the types of devices that are covered, how this coverage works, and any costs for which you may be responsible.
If you are on Original Medicare, doctors and suppliers of prosthetic devices and DME are required to file a claim for the device you need. You must assist in securing this documentation by contacting your doctor or supplier and asking them to file a claim. If they do not file a claim, call 800/MEDICARE. Ask for the exact time limit for filing a Medicare claim for the service or supply you received. If it’s close to the end of the time limit and your doctor or supplier still hasn’t filed the claim, you should file the claim yourself.
The Amputee Coalition has additional information on Medicare coverage of prosthetic devices.
|If you are on Medicare, you may also be eligible for Medicaid and CHIP Program coverage.Unfortunately, prosthetic devices are categorized as an optional benefit under Medicaid. However, individuals with disabilities who are eligible for Medicaid are entitled to all services that are deemed medically necessary. Also, because prosthetics and rehabilitative services are now considered an Essential Health Benefit (EHB) under the Affordable Care Act, states that have expanded their Medicaid programs must provide these benefits to people newly eligible for coverage.
For more information on how Medicaid can help you get coverage for your prosthetic device or DME, visit Medicaid’s Individuals With Disabilities page.
Medicaid programs are run by individual states. You can find information for your state’s Medicaid program by clicking the online map.
|In order to be eligible for enrollment in healthcare through the VA, 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)
· Served as a National Guard member or reservist for the entire period for which you were called to active duty, other than for training purposes only.
The Veterans Administration’s Rehabilitation and Prosthetic Services is responsible for the national policies and programs for medical rehabilitation, and prosthetic and sensory aids services that promote the health, independence and quality of life for veterans with disabilities. To find out more about this service, go to http://www.prosthetics.va.gov.
The VA Web site provides instructions and contact information if you want to apply for VA health benefits.
|TRICARE is the Department of Defense’s worldwide healthcare program for active duty and retired uniformed service members and their families. TRICARE covers prosthetics, prosthetic devices and prosthetic supplies necessary because of injuries resulting from trauma, congenital anomalies or disease. TRICARE also covers:· Any accessory or item of supply that is used with the device for the purpose of achieving therapeutic benefit and proper functioning
· Services necessary to train the patient to use the device
· Repair of the device for normal wear and tear or damage
· Customization of the prosthetic when provided by an authorized provider
· Replacement when required due to: growth or a change in the patient’s condition; if the device is lost or irreparably damaged; or the cost of repair would exceed 60% of the cost of replacement
· Surgical implants that are approved for use in humans by the U.S. Food and Drug Administration (FDA).
Prosthetic devices with an FDA-approved investigational device exemption (IDE) categorized by the FDA as non-experimental/investigational (FDA Category B) will be considered for coverage. Coverage is dependent on the device meeting all other requirements of the law and rules governing TRICARE and upon the beneficiary involved meeting FDA-approved IDE study protocols.
This list of covered services is not all-inclusive. TRICARE covers services that are medically necessary and considered proven. There are special rules or limits on certain services, and some services are excluded.
To find out more about your TRICARE options, visit the TRICARE Plans page.
|Most states have vocational rehabilitation programs that provide assistance to people with limb loss or other disabilities in obtaining and keeping employment, or if a prosthesis or other adaptive device is designated as a daily living aid. These programs vary widely from state to state as to eligibility requirements and services. Some may fund prosthetic care if it is determined to be necessary for employment, or if the device allows for greater independence. Assistive devices such as wheelchairs, lifts and adaptive driving equipment are often furnished to enable a person to get to work. Devices necessary for job performance are usually provided as well.Contact your state’s Department of Health and Human Services office in order to find out about specific programs available to you. You can find answers for many of your questions on the Vocational Rehabilitation FAQS page.|
|The Affordable Care Act (“Obamacare”), passed in 2010, requires that every individual in the country has health insurance coverage. Not enrolling in health insurance will mean that you must pay a tax penalty each year. If you already have an insurance plan, you may be able to keep it if it meets minimum requirements. If you decide you need to sign up for a new private health insurance plan, you may do so independently, through your employer, or through the new insurance exchanges, called marketplaces. These insurance exchanges have been set up in each state. They will allow you to compare costs and coverage of various insurance plans and help you determine if you qualify for discounts or tax credits to help cover the costs of your health insurance.The Affordable Care Act established provisions relating to Essential Health Benefits (EHB). An Essential Health Benefit is a benefit that insurance policies must cover in order to be certified and offered in the marketplace. If a benefit is deemed an EHB, then that benefit cannot be subject to caps. States expanding their Medicaid programs must provide these benefits to people newly eligible for Medicaid. The statute itself establishes 10 categories of EHBs that, in theory, must be covered by every insurance plan that is going to receive any federal money. These categories include rehabilitative and habilitative services and devices, but the Department of Health and Human Services elected to allow states to define their own EHBs.
Unfortunately, many states did not explicitly include prosthetic devices in their EHBs. However, nearly every state appears to have at least some level of coverage for prosthetic care.
For further information on open enrollment, your state’s insurance marketplace, and coverage for prosthetic devices and DME under various health insurance options, take a look at the Amputee Coalition’s Fact Sheet on Open Enrollment for Insurance Coverage.
Medical Discount Programs
|Medical discount programs negotiate with Preferred Provider Organization (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 DME is often included in the benefits packages provided in the programs, prosthetic care is usually not specifically mentioned. The Federal Trade Commission Web site provides more information on health insurance versus discount plans.|
Certain nonprofit organizations provide grants that assist amputees in acquiring prosthetic devices. See below to find out how you can benefit from this funding.
|Amputee Blade Runners
356 24th Avenue North, Suite 300
Nashville, TN 37203
|Amputee Blade Runners is a nonprofit organization that helps provide free running prosthetics for amputees. Running prosthetics are not covered by insurance and are considered “not medically necessary,” so this organization helps amputees keep an active lifestyle. Their goal is to provide a running prosthesis to one athlete in all 50 states by 2016. They currently have athletes in 24 states who serve as ambassadors to other amputee athletes.To apply, you must fill out an application and send it to the address to the left or email it to firstname.lastname@example.org.|
|Challenged Athletes Foundation(CAF)
9591 Waples St.
San Diego, CA 92121
|To be eligible for a grant through the Challenged Athletes Foundation’s flagship program, Access for Athletes, an athlete’s physical disability must be recognized within the International Paralympic Committee (IPC) classifications. For more information, please visit the IPC Web site.Interested applicants may apply for grant funding for coaching fees, competition expenses or equipment.CAF does not discriminate based on age, gender, level of ability or sport, but does require applicants to demonstrate a clear financial need for their grant request.|
|Limbs for Life Foundation
|Limbs for Life provides assistance for lower-limb amputees. The applicant must be a U.S. citizen or a permanent resident of the U.S. They must have no other means to pay for prosthetic care, including Medicare, insurance coverage or state assistance. They must work with a prosthetist or clinic that agrees to accept LFL payment as full payment for their services.Eligible candidates must fill an application for assistance.|
|National Amputation Foundation
40 Church Street
Malverne, NY 11565
|The National Amputation Foundation’s donated medical equipment is available to any person in need through their Medical Equipment Give-A-Way Program. This includes wheelchairs, walkers, commodes, canes and crutches. While this program is open to anyone in need, the item(s) need to be picked up at the Foundation’s office.To learn about how you can benefit from the National Amputation Foundation’s Medical Equipment Give-A-Way Program, visit nationalamputation.org.|
|Local Service Clubs||Lions, Rotary, Elks, Shriners or any other fraternity or special interest groups in your community could provide dollars or assistance in fundraising. You can contact the respective local organization for further information.For assistance in finding a local service club, contact the Amputee Coalition’s Resource Center at 888/267-5669.|
Various organizations specialize in assisting children in need of prosthetic devices. These are listed below.
|Programs for Children with Special Healthcare Needs (CSHCN)||Each state has a Title V CSHCN program administered through the Department of Health and Human Services (DHHS). Unfortunately, there is not a comprehensive online directory of these services, so you will need to contact your state’s DHHS office in order to find out about specific programs available to you.|
|State Children’s Insurance Program (CHIP)||If your children need health coverage, they may be eligible for CHIP. If they qualify, you won’t have to buy a Marketplace plan to cover them.CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. In some states, CHIP covers parents and pregnant women. Each state offers CHIP coverage, and works closely with its state Medicaid program.You can visit the CHIP Web site to enroll; to learn more about the program, visit InsureKidsNow.gov.|
|Administration for Children and Families (ACF)||The ACF is a division of the Department of Health & Human Services. They promote the economic and social well-being of families, children, individuals and communities.The grants available through ACF vary over time, and there may or may not currently be a grant available for prosthetic devices or DME. To see grant opportunities and eligibility requirements, visit the ACF’s Funding Opportunity Announcements page. Check back often to see if opportunities become available.To learn how to apply for a grant through this organization, visit http://www.acf.hhs.gov/grants/howto.
For FAQs concerning the application process, visit http://www.acf.hhs.gov/faqs-on-the-acf-application-process.
|Shriners Hospital provides free orthopedic care to children under the age of 18 if there is a reasonable possibility that the child’s condition can be helped.|
|St. Jude Children’s Research Hospital901/595-3300
|Children may receive prosthetic care at St. Jude’s in conjunction with treatment of a catastrophic illness such as osteosarcoma. Acceptance for treatment is based solely on a patient’s eligibility for an ongoing clinical trial at the hospital. To determine if your child is eligible, your physician must:· Call the referral line at 888/226-4343.· Fax relevant information to 901/495-4011.
· Complete a referral online by visiting https://hospital.stjude.org/apps/hospitalforms/fb/physicianReferral.
For more information on referring a patient to St. Jude’s, go to http://www.stjude.org/referapatient.
|Blue Cross Blue Shield (BCBS)||Some BCBS companies have established “Caring for Children Foundations” that provide free or low-cost coverage to children who are not insurable through Medicaid or private insurance. Some of these foundations work with the CHIP programs in their states. Others work independently and accept no government funding. Services and eligibility requirements vary. Call your local BCBS office or visit http://www.bcbs.com/ for more information.|
|Variety – The Children’s Charity of the United States
|Variety aids children with physical challenges whose families cannot afford, nor obtain through insurance, necessary mobility equipment such as wheelchairs, walkers, strollers, specially designed adaptive bikes, and other mobility devices.Variety provides funding for the equipment that helps them not only exercise and grow stronger, but also helps them engage with family, friends and classmates to become confident, independent, active members of their communities.|
3. What if I Feel that I Have Been Wrongly Denied Assistance?
If you are on Medicare, you can file an appeal if you think you have been wrongly denied coverage by going to http://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html.
You can also file a complaint if you feel you have been discriminated against or have other concerns about the treatment you have received by visiting http://www.medicare.gov/claims-and-appeals/file-a-complaint/complaint.html.
Call 800/MEDICARE (800/633-4227) for more information.
Protection and Advocacy (P&A)/Client Assistance Program (CAP)
In an effort to address public outcry in response to the abuse, neglect and lack of programming in institutions for people with disabilities, Congress created a system in each state and territory that provides protection of the rights of people with disabilities through legally based advocacy. The governor in each state designated an agency to be the Protection and Advocacy (P&A) system and provided assurance that the system was and would remain independent of any service provider. This federally mandated system includes several programs. Those most likely to be of assistance to people with limb loss are:
- The Protection and Advocacy of Individual Rights (PAIR) Program, established to protect and advocate for the legal and human rights of all people with disabilities
- The Protection and Advocacy for Assistive Technology (PAAT) Program, created to assist people with disabilities and their family members, guardians, advocates and authorized representatives in accessing technology devices and assistive technology services through case management, legal representation and self-advocacy training.
The Client Assistance Program (CAP) was established by 1984 Amendments to the Rehabilitation Act as a condition for receiving allotments under Section 110. CAP services include assistance in pursuing administrative, legal and other appropriate remedies to ensure the protection of people receiving or seeking services under the Rehabilitation Act.
If you have received unsatisfactory services or have been denied services to which you believe you are entitled under federally funded programs, your state’s P&A or CAP should provide assistance. To find out more, go to http://pandasc.org/.
4. Additional Resources
AgrAbility Project: http://www.agrability.org
The vision of AgrAbility is to enhance quality of life for farmers, ranchers and other agricultural workers with disabilities. While the term “disability” often brings to mind conditions such as spinal cord injuries and amputations, AgrAbility addresses not only these but also many other conditions, such as arthritis, back impairments and behavioral health issues. Through education and assistance, AgrAbility helps to eliminate (or at least minimize) obstacles that inhibit success in production agriculture or agriculture-related occupations.
AgrAbility is sponsored by the U.S. Department of Agriculture (USDA) and consists of a National Project and State/Regional Projects (currently serving 24 states), each involving collaborative partnerships between land grant universities and various nonprofit disability services organizations.
Area Agencies on Aging: http://www.n4a.org
The National Association of Area Agencies on Aging’s primary mission is to build the capacity of its members to help seniors and people with disabilities live with dignity and choices in their homes and communities for as long as possible.
Centers for Independent Living: http://www.ilru.org/projects/cil-net/cil-center-and-association-directory
A Center for Independent Living is a consumer-controlled, community-based, cross-disability, nonresidential private nonprofit agency that is designed and operated within a local community by individuals with disabilities and provides an array of independent living services.
National Insurance Marketplace: http://www.healthcare.gov
Amputee Coalition’s Open Enrollment Fact Sheet: http://www.amputee-coalition.org/fact_sheets/open-enrollment.html
Amputee Coalition’s Medicare for People with Limb Loss Fact Sheet: http://www.amputee-coalition.org/resources/medicare-for-people-with-limb-loss/
It is not the intention of the Amputee Coalition to provide specific medical or legal advice but rather to provide consumers with information to better understand their health and healthcare issues. The Amputee Coalition does not endorse any specific treatment, technology, company, service or device. Consumers are urged to consult with their healthcare providers for specific medical advice or before making any purchasing decisions involving their care.
National Limb Loss Resource Center, a program of the Amputee Coalition, located at 900 East Hill Ave., Suite 390, Knoxville, TN 37915 | 888/267-5669
© Amputee Coalition. Local reproduction for use by Amputee Coalition 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 for permission to do so.