Different Coverage for Different Situations

Each patient’s coverage will be different based on a number of important factors, including the nature of your disability and your provider’s specific guidelines. At North Carolina Orthotics & Prosthetics, we help patients navigate these complexities, and help manage your expectations as to what is covered and what isn’t. After all, we want you to have the best possible outcome, both with your device and your coverage.

NCOPI participates in the following insurance networks and plans:

If your insurance is not listed above, we can verify any out of network benefits. For any questions, please contact (252) 436-2611 and speak to one of our Insurance Specialist.

Committed to Maximizing Your Coverage

We plan on being your O&P specialist for life. So, we will act as your professional advocate to help you receive the maximum amount of coverage available under your policy or under law. That means we will continuously communicate with – and often appeal to — your insurance provider.

We recommend patients keep the following guidelines in mind:

Get a detailed prescription! We will work with your physician to ensure that your prescription is accurate, thereby enabling you to get the best care and coverage possible.

Be patient. Often, obtaining maximum coverage can take weeks, if not months. While we will do everything we can to expedite the process, many insurance providers need time to study each case closely to verify the level of coverage allowed.

YOU are your own best advocate. As mentioned earlier, we will work with you throughout the process to obtain any authorizations needed, however, in our experience, the most persuasive advocate for coverage is YOU, since you are the one whose life is impacted, you are the one paying the premiums and you are the insurance customer.

Call us when you’re thinking about a new insurance policy. Many disabled people get phone calls from insurance companies who claim they can offer more coverage. So please call us so we may help you understand your options, and what would be covered in your specific situation with any insurer.

Payment plans are available. Even with insurance coverage, the out-of-pocket for an orthotic or prosthetic device can be costly. Please contact our Insurance Specialist at (252) 436-2611 to learn more about your options.

Coverage for transportation available. Through your local NC Division of Medical Assistance, you may qualify for Medicaid-sponsored transportation to our offices.

Be honest with yourself and your practitioner. Devices built for active people are generally more expensive and more difficult for insurance companies to cover. If you lead an active life and need a device to continue leading that life, we’ll work with you to justify a device’s coverage to your insurance provider. If, you aren’t already leading an active lifestyle and still want a device more suited for an active individual, your chances of obtaining maximum coverage are less.

Understanding Medicare Coverage

For patients who qualify for Medicare, coverage can vary, depending on your potential activity levels and mobility. Medicare has defined these five levels, or “K Levels,” of activity and mobility to help determine which device and coverage level is right for you: The more you’re capable of, the higher the level of device you will receive coverage for. Your levels will be determined by your physician, which typically includes a consultation with your Prosthetist. Over time, your K-Level can be adjusted according to changes in your mobility.

Functional Level 0: The patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance his/her quality of life or mobility.

Functional Level 1: The patient 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.

Functional Level 2: The patient 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.

Functional Level 3: The patient 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 utilization beyond simple locomotion.

Functional Level 4: The patient 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.

Improving Prosthetic Coverage for Everyone

The Amputee Coalition of America is actively lobbying on your behalf to improve coverage and obtain what is called “Parity” in the coverage of prosthetic and orthotic devices. While several states have been successful in improving coverage by passing ‘Parity’ legislation, North Carolina does not have these improved coverage laws in place.

To learn more about this effort, click here . To learn more about the ACA’s efforts nationwide, visit their website. In addition, we’ll be addressing these political issues from time to time on our blog.