Insurance Deductible and Co - Pay
Contact your insurance company before your first appointment to determine your benefits for orthotic and prosthetic care. Most health insurance policies require patients to pay for some portion of their health care expenses. This amount is commonly referred to as a deductible and co-pay.
- Deductible – dollar amount that a patient has to pay to healthcare providers before their health insurance kicks in. This amount varies depending on the insured's specific policy, but typically ranges from $250 to $1,000.
- Co-pay – once the deductible has been met, insurers typically require patients to pay for some percentage of their treatment. For example, if your co-pay is 20 percent with a maximum out-of-pocket expense of $500, this means that once you've paid $500 toward your care, in addition to paying your deductible, then your insurance will pay for the rest of your treatment.
For Medicare patients, 80% of the "fee schedule" for prosthetic and orthotic services are covered once the annual deductible is met. The device has to be medically appropriate, physician-prescribed, and meet Medicare's coverage criteria. Generally, there aren't any caps on the types of technology utilized.
Additional information about Medicare and its policies are available at 1-800-MEDICARE, or www.medicare.gov
Forms to Complete Before Your Appointment
Once you have an appointment with Virginia Prosthetics, please download the following forms by clicking on each one. Completing and printing each form prior to your visit will help save you time at your first visit.
Having health insurance doesn't, unfortunately, guarantee that your prosthesis or orthosis is covered. At Virginia Prosthetics, we're working with state and national government leaders to change that. Until we do, it's important to determine exactly what your insurance covers before you begin treatment. Our staff will assist you in researching your benefits.
Even if your prosthetic or orthotic care isn't covered by your insurer, there may be other resources available to provide you with assistance. We've listed some of them below.
The term "Prosthetic Parity" simply means that commercial health insurance carriers are required to provide coverage for prosthetic devices and components, including their repair and replacement. This essentially puts prosthetic care on par with other critical medical and surgical services.
Virginia Prosthetics supports our patients' rights to prosthetic parity, and we were the leader in the Virginia fight for passage of parity legislation. Together with the Amputee Coalition of America and several other Virginia O&P providers, we were able to pass a parity bill (SB1116) in the 2009 Virginia General Assembly session. This bill requires health insurers, health care subscription plans, and health maintenance organizations to offer and make available coverage for medically necessary prosthetic devices, their repair, fitting, replacement, and components, to replace a limb.
Unfortunately, we can't stop yet. The fight for amputees looming on the horizon now is in Washington, D.C. Amputees must be vigilant as to how the current Administration and Congress will treat prosthetics in the proposed health care plan. You can help to ensure that amputees are treated fairly by contacting your U.S. Senator and Congressman and letting them know that you want prosthetic and orthotic coverage included in any new health care plan.
Trouble With Your Insurance Company
If you feel that your insurance company is refusing to pay a legitimate claim fairly and promptly, Virginia has an agency that will investigate your complaint and is empowered to force the insurance company to comply if they are found to be in violation of Virginia regulation or your health insurance contract.
Always attempt to resolve the matter directly with your health insurance company first. There is a great deal of very helpful information on the Amputee Coalition of America's web site at www. Amputee-coalition.org
If after attempting to settle the matter with your insurance company, you still need assistance you can contact the Virginia State Corporation Commission's Bureau of Insurance. Their web site information address is: www.state.va.us/scc/division/boi The Bureau of Insurance is the state agency that is empowered with responsibility for regulation and enforcement of the insurance industry. The BOI has several publications available on their website that are helpful and informative.