top of page
Search

Understanding Prosthetic Authorizations During Open Enrollment: What You Need to Know

Getting a prosthetic device approved through your insurance can be a complex and frustrating process. The steps you need to take depend heavily on the type of insurance plan you have. Open enrollment season is the perfect time to review your options and understand how different plans handle prosthetic authorizations. Knowing the differences between HMO, PPO, Medicare, and Medicare Advantage plans can help you avoid delays and get your prosthetic device and/or supplies when you need it.

This guide breaks down how each insurance type manages prosthetic authorizations, what you should consider before choosing a plan, and practical tips to navigate the approval process more smoothly.



How HMO Plans Handle Prosthetic Authorizations


Health Maintenance Organization (HMO) plans require you to work closely with your primary care physician (PCP) before you can move forward with prosthetic care. This structure can impact both the timeline and flexibility of your authorization.


PCP Submission Required

Your primary care physician must submit the authorization request for your prosthetic device. You cannot bypass your PCP to work directly with your prosthetist.


Potential Delays Due to Documentation

PCPs may not always be familiar with prosthetic documentation requirements. Missing details or insufficient medical justification can cause back-and-forth communication, slowing down approval. They also tend to be pretty busy offices so submissions can be delayed. 


Strict Network Rules and Referrals

HMOs typically require referrals and limit coverage to in-network providers. If your prosthetist is out-of-network, you may face higher costs or denied coverage.


Lower Premiums, More Steps

HMOs usually have lower monthly premiums, but require more administrative steps and offer less flexibility.


Example: If you have an HMO and need a new prosthetic leg, your PCP will need to evaluate your condition and submit the paperwork. If they are unfamiliar with prosthetic requirements, approvals may take longer. Our staff will help guide the process but it can take some time to educate the PCP staff. 



How PPO Plans Simplify Prosthetic Authorizations


Preferred Provider Organization (PPO) plans are often more patient-friendly when it comes to prosthetic approvals.


No Referral Needed

You can contact your prosthetist directly without seeing your PCP first.


Prosthetist Submits Documentation

Your prosthetist can send all required documentation to your insurer, which usually speeds up the process.


Out-of-Network Options

PPOs cover in-network and some out-of-network providers, increasing your choices.


Higher Premiums, Greater Flexibility

While PPOs tend to cost more per month, they give you more control when selecting specialists.


Example: If you prefer a prosthetist who specializes in advanced technology but is out-of-network, a PPO may still offer partial coverage while allowing the prosthetist to manage all documentation.



Understanding Prosthetic Coverage Under Original Medicare


Original Medicare (Parts A and B) remains one of the most straightforward options for prosthetic authorization.


Any Medicare-Approved Provider Can Supply Prosthetics

No network restrictions mean you can choose any provider who accepts Medicare.


Direct Documentation Submission

Your prosthetist and physician submit documentation directly to Medicare, often speeding up approval.


Part A and Part B Coverage

Part A covers inpatient care; Part B covers outpatient prosthetic care, fittings, and follow-ups.


Fewer Restrictions

Original Medicare generally involves fewer prior authorization requirements than private insurance.


Example: If you were hospitalized and need a prosthesis after discharge, Medicare Part A may cover inpatient care while Part B covers the device and outpatient services.

Source: CMS.gov



Medicare Advantage Plans and Prosthetic Authorizations


Medicare Advantage (Part C) plans are administered by private insurers and may operate like HMOs or PPOs. This affects how authorization works.


Managed by Private Insurers

Rules vary significantly across plans.


PCP Authorization Often Required

Many Medicare Advantage HMOs follow a PCP-first model, similar to standard HMOs.


Stricter Prior Authorization Rules

Compared to Original Medicare, these plans often require more documentation and additional justification.


Network Restrictions Apply

Coverage is usually limited to the plan’s provider network.

Example: If you have a Medicare Advantage HMO, your PCP may have to initiate authorization before your prosthetist can submit additional documents, adding extra steps.

Sources: CMS.gov, KFF.org



Key Factors to Consider When Choosing an Insurance Plan


Before selecting or switching your insurance during open enrollment, consider the following questions:

  • Who submits prosthetic authorizations—your PCP or your prosthetist?

  • Are referrals required?

  • How fast does the plan process authorizations?

  • Are your prosthetist and preferred providers in-network?

  • What are your deductibles, copays, and out-of-pocket limits?


Seniors can get free assistance from SHINE. Source: FloridaShine.org



Tips to Avoid Delays in Prosthetic Authorization


A few proactive steps can help you move through the approval process with fewer complications:


Communicate Early with Your PCP and Prosthetist

Make sure everyone understands the required documentation. Refer to our website links for physician not requirements. Make an appointment with your physician to discuss only your prosthesis and bring the checklist with you. Ask our staff for more information on having this conversation with your physician. 


Keep Copies of All Documents

This helps with follow-ups and appeals.


Ask Your Prosthetist About Their Experience with Your Insurance

Experienced prosthetists know how to streamline submissions.


Review Your Insurer’s Prior Authorization Rules

Some insurers publish turnaround times and required forms.


Consider Working with a Case Manager

Some providers or insurance plans offer individuals who help coordinate care.







References

  1. Healthcare.gov – Official Health Insurance Marketplace Information https://www.healthcare.gov

  2. Centers for Medicare & Medicaid Services (CMS) – Medicare Coverage & Policy https://www.cms.gov

  3. Kaiser Family Foundation (KFF) – Medicare Advantage & Health Policy Research https://www.kff.org

  4. Florida SHINE (Serving Health Insurance Needs of Elders) – Free Medicare Assistance for Seniors https://www.floridashine.org


 
 
 
bottom of page