by Russell Noga | Updated February 5th, 2024
Are you looking to understand if Medicare supports the costs for orthotics? Simply put, does Medicare cover orthotics when deemed medically necessary? Yes, it does, but there are specific requirements and limitations to be aware of. Keep reading to discover the guidelines that determine eligibility for Medicare orthotics coverage, the extent of such coverage, and additional insights to navigate potential out-of-pocket expenses.
Key Takeaways
- Medicare Part B covers orthotics, including splints, braces, and shoe inserts, when prescribed by a physician and deemed medically necessary, with beneficiaries responsible for 20% of the cost after meeting the annual deductible.
- Medicare provides coverage for specific conditions, such as severe diabetic foot disease, plantar fasciitis and post-surgery assistance, covering orthotic devices like therapeutic shoes and inserts based on medical necessity.
- While Medicare covers a range of podiatric services and orthotic devices, it does not cover routine foot care services. Medicare Advantage plans may offer additional benefits, including coverage for over-the-counter orthotics and podiatric services related to diabetes-related nerve damage.
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Medicare and Orthotics: The Basics
Orthotics, including splints, braces, or shoe inserts, are designed to support injured, deformed or inadequately supported muscles, joints, or parts of the skeleton. They fall under Medicare’s coverage, provided they are medically necessary and prescribed by a physician. They are included in Medicare Part B when a physician considers orthopedic care, which includes the use of orthotic devices, to be medically necessary.
After meeting your annual deductible, Medicare shoulders 80% of orthotics expenses, leaving you the remaining 20%. Remember, a prescription from a qualified medical professional that confirms the orthotics’ medical necessity is required to secure Medicare Part B coverage.
Custom Orthotics Coverage Under Medicare Part B
Specific conditions qualify you for coverage of custom orthotics under Medicare Part B, including severe foot disease and diabetes. Coverage includes one pair of custom-molded shoes, one pair of custom-molded inserts, one pair of extra depth shoes medicare, and additional inserts for custom-molded and extra-depth shoes.
Beneficiaries need to pay 20% of the cost for one pair of custom-fitted shoes or inserts per year for approved conditions. Despite this, the out-of-pocket expense is relatively small compared to the total cost of these vital medical devices.
Orthotic Devices as Durable Medical Equipment
Orthotic devices, such as braces for different body parts and orthopedic shoes incorporated into a leg brace, are classified as durable medical equipment (DME) under Medicare. This classification is significant because Medicare has a specific provision for covering DME.
To be eligible for coverage, the orthotic device must:
- Be durable
- Be medically necessary
- Not be beneficial for individuals without a disability or illness
- Typically intended for use by the patient only
For instance, leg brace prosthetic devices are eligible for coverage if they meet these criteria.
Orthotics for Specific Conditions: What's Covered?
Orthotics can be a game-changer for individuals suffering from conditions such as severe foot disease and diabetes, which often result in foot pain. These conditions can drastically affect a person’s quality of life, making simple tasks like walking or standing uncomfortable. So, can Medicare offer some reprieve?
Yes, Medicare provides coverage for therapeutic shoes and inserts for individuals with diabetes, under the Therapeutic Shoes for Individuals with Diabetes benefit. Medicare Part B may cover 80% of the cost for these orthotic devices if they are prescribed by a physician as medically necessary for severe diabetic foot disease.
Furthermore, orthotic devices prescribed by a doctor and deemed medically necessary for Plantar Fasciitis are typically covered by Medicare. Post-surgery orthotic devices prescribed for chronic conditions like arthritis or for injuries such as whiplash, are also covered under Medicare Part B.
Diabetic Foot Disease and Therapeutic Shoes
Foot complications are common in individuals with diabetes, making orthotic support essential in many cases. Medicare acknowledges this and provides coverage for therapeutic shoes and inserts for diabetic patients with severe foot disease, including one pair of custom-fitted shoes per year.
However, to be eligible for this coverage, diabetic patients must meet specific criteria, which include:
- Having diabetes
- Ensuring that their doctors and suppliers are enrolled in Medicare
- The physician managing your diabetes must validate your requirement for therapeutic shoes or inserts
- A podiatrist or another qualified physician must issue the prescription
- You must then acquire the shoes or inserts from a podiatrist or another qualified professional.
Plantar Fasciitis and Medicare Coverage
Plantar Fasciitis, a common cause of heel pain, can be debilitating, affecting your mobility and daily life. Good news is, Medicare may cover orthotics for plantar fasciitis if they are determined to be medically necessary and are prescribed by a physician.
Medicare will provide coverage for orthotics to treat plantar fasciitis if your healthcare providers and suppliers are registered with Medicare and if the orthotics are deemed medically essential. In fact, some Medicare Advantage plans commonly provide coverage for orthotics for plantar fasciitis if they are considered medically necessary by a physician and if the individual has either diabetes or severe foot disease.
Post-Surgery Orthotic Support
Orthotic support often becomes a necessity after surgery. Medicare Part B provides coverage for custom-made or pre-made orthotic devices following surgeries such as ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO).
While coverage for orthotic devices post-surgery may be subject to limitations, Medicare generally covers devices such as ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO). In case of a severe stress fracture, if a medical professional determines surgery is essential, Medicare Part A will provide coverage for the surgical procedure and the related hospital expenses.
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Podiatry Services and Medicare
Now, let’s shift the focus to podiatry services, another aspect of foot care. Medicare Part B provides coverage for podiatry services related to medically necessary treatment of foot injuries, diseases, or other medical conditions affecting the foot, ankle, or lower leg. This includes coverage for treatments for conditions like bunions and stress fractures.
Bear in mind that routine foot care services, including removal of calluses and corns, nail cutting, trimming, or removal, and hygienic or preventive maintenance, are generally not covered by Medicare.
Morton’s Neuroma Treatment
Morton’s Neuroma is a painful condition caused by the inflammation of a nerve in the foot, often resulting in a sensation similar to stepping on a marble. Fortunately, Medicare provides coverage for the treatment of Morton’s Neuroma through podiatry services.
Coverage includes non-surgical treatments like metatarsal pads and cortisone injections. And in cases where surgical intervention is required, Medicare provides coverage. So if you’re dealing with this painful condition, take a sigh of relief knowing Medicare has got your back.
Bunions and Medicare Coverage
Bunions, those painful bony bumps that develop on the joint at the base of your big toe, can be a source of constant discomfort. If you’re grappling with this condition, you’ll be relieved to know that Medicare does have provisions to cover treatments.
Bunion treatments that are eligible for coverage under Medicare may encompass non-surgical options like bunion pads, toe spacers, or shoe inserts. In more severe cases, Medicare may also provide coverage for bunion surgery. However, patients must satisfy the criteria that the treatment is medically necessary as part of addressing foot injuries or diseases.
Stress Fractures and Medicare
Stress fractures are painful and can seriously hamper mobility. Thankfully, Medicare Part B provides coverage for the treatment of stress fractures, including any required tests, braces, and crutches.
The treatment is deemed medically necessary when prescribed by a qualified medical professional. And in severe cases, if surgery is required, Medicare Part A will cover the surgical procedure and related hospital expenses.
Non-Covered Podiatric Care: What to Expect
While Medicare extensively covers various foot conditions and treatments, it doesn’t cover everything. Routine foot care services, including callus and corn removal, nail cutting, trimming, or removal, and hygienic or preventive maintenance, aren’t covered unless certain medical conditions qualify for an exception.
The expense for podiatric services not included in Medicare coverage can vary, with an average visit costing between $50 to $300. These expenses are out-of-pocket and are the responsibility of the beneficiaries to pay. Therefore, it’s crucial to consider these potential costs when planning your healthcare budget.
Medicare Advantage Plans and Orthotic Coverage
Original Medicare provides comprehensive coverage, including the fact that Medicare covers orthotics. However, Medicare Advantage plans, available through medical insurance companies approved by Medicare, might offer extra Medicare cover orthotics benefits.
Medicare Advantage plans offer supplementary coverage for orthotics, including therapeutic shoes and inserts, if they are determined to be medically necessary. Moreover, certain plans may include coverage for over-the-counter products, including orthotics.
In addition, Medicare Advantage plans may provide coverage for essential podiatric services, including treatment for foot injuries or nerve damage related to diabetes.
Navigating the Costs: Orthotics and Medicare
While Medicare offers substantial orthotics coverage, beneficiaries must understand that they still bear a portion of the costs. For custom foot orthotics, beneficiaries are responsible for 20% of the cost after meeting their annual Medicare Part B deductible.
The annual deductible for Medicare Part B in 2024 is $240. After this amount is met, Medicare will cover 80% of the medicare approved cost for services like orthotics. It’s crucial to keep these costs in mind when planning for your healthcare expenses, as well as understanding how medicare pay factors into your overall financial planning.
Obtaining a Prescription for Custom Orthotics
Should you require custom orthotics, a prescription is necessary. Medicare covers custom orthotics if they are prescribed by a Medicare-enrolled physician, nurse practitioners, or physician assistants, adhering to the scope of practice laws in the respective state.
The procedure for obtaining a prescription entails:
- A comprehensive assessment conducted by a podiatrist to evaluate your feet, ankles, and legs.
- A thorough foot examination.
- The creation of a personalized mold to ensure proper fitting of the orthotics.
The prescription needs to distinctly indicate the medical necessity of the custom orthotics for the patient.
Summary
In conclusion, while navigating the intricacies of Medicare’s coverage for orthotics can seem daunting, it’s clear that Medicare provides significant support for those in need. From coverage for custom orthotics and post-surgery support to treatments for specific foot conditions like diabetes, plantar fasciitis, and bunions, Medicare has you covered. Just remember, it’s crucial to understand your Medicare plan, meet deductibles, and obtain necessary prescriptions to fully reap these benefits.
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Frequently Asked Questions
Does Medicare cover orthotics 2023 for seniors?
Yes, Medicare covers orthotics for seniors if they are deemed medically necessary by a doctor and the supplier is enrolled in Medicare. Medicare Part B usually covers 80% of the Medicare-approved cost.
Does Medicare pay for a foot orthotic?
Yes, Medicare will cover 80% of the costs for foot orthotics under the DME or DMEPOS benefit, leaving you responsible for the remaining 20% after meeting your deductible. It’s important to ensure that your doctor and supplier are enrolled in Medicare.
How much can I expect to pay for orthotics?
You can expect to pay anywhere from $200 to $800 for custom orthotics, in addition to additional costs for office visits and replacing the top surfaces. The cost of resurfacing a pair of orthotic inserts ranges from $50 to $100.
What orthotic devices does Medicare cover?
Medicare covers orthotic devices like splints, braces, and shoe inserts that offer support for injured or deformed muscles and joints, as long as they are prescribed by a physician and considered medically necessary.
Are routine foot care services covered by Medicare?
No, routine foot care services are not covered by Medicare unless there are specific medical conditions that qualify for an exception. Therefore, it’s important to understand the coverage criteria before seeking these services.
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Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.