Are Orthotics Covered by Blue Cross Blue Shield Insurance?

Orthotics have been a life saver for many people suffering from different foot-related conditions. With its ability to offer relief from conditions such as flat feet, plantar fasciitis, diabetic foot issues and more, a lot of people have practically come to depend on it.

However, with the high cost that some of these devices, especially the custom-made ones, we find ourselves having to always answer this question - are orthotics covered by Blue Cross Blue Shield (BCBS) insurance?

This is not a question with a yes or no answer as there are certain factors that will determine the answer you will get. In this article, we'll, therefore, be exploring the different factors that will determine the answer to the question asked.

An Overview of Blue Cross Blue Shield Insurance

BCBS is an association that includes about 33 different health insurance companies and licensees. This network of companies makes it possible for the BCBS health cover to extend to all the states across the entire nation including Puerto Rico.

Though these different organizations operate under the umbrella of BCBS, their policies differ from state to state. These policies must however meet the requirements of the Affordable Care Act which include providing coverage for preventive care, prescription drugs, emergency services and anything that can be regarded as an essential health need.

Does Blue Cross Blue Shield Insurance Cover Orthotics?

When it comes to orthotics, BCBS will mostly provide coverage but the coverage offered will depend on the plan you are on. Generally, the benefits that will be offered for durable medical equipment (DME), under which orthotics fall, will differ from plan to plan.

For clarity, BCBS defines durable medical equipment (DME) as any equipment that provides therapeutic benefits to a patient with specific needs resulting from a medical condition and/or illness. Qualifying equipment must therefore possess the following criteria:

·         It must be reusable

·         Its primary purpose is a medical one

·         The device will not be useful if the condition no longer exists

·         The patient can use it at home

·         Can only be gotten with a doctor's prescription

Looking at the criteria, orthotics certainly fits the bill.

All of that said, most plans will cover orthotics under its durable medical equipment benefits but only if it meets the following criteria:

Medical Necessity

The device must be required for the treatment or management of a specific condition and this has to be confirmed by a qualified healthcare provider. This therefore also means that a prescription will be required to prove this medical necessity.

Documentation

Aside from your doctor's prescription, you may also need to have proper documentation showing proof that the device is indeed required. This will include any tests that were done and the associated clinical notes.

Coverage Offered in Plan

Like we stated earlier, coverage is often plan-specific. There are plans that have a maximum number of orthotics that you can get within a specific period. In fact, in North Dakota, Blue Cross Blue Shield covers orthotics for only one foot in a year. Some others will cover only custom orthotics while Medicare Advantage plans will cover diabetic patients who need orthotics to prevent foot ulcers.

Aside from these three points listed above, when the healthcare provider issuing the prescription and the supplier of the orthotics are both in-network with your BCBS plan, the orthotics is more likely to be covered.

How to Verify Your Coverage

If you want to know if your BCBS plan will cover your need for orthotics, then take the following steps:

·         Carefully Go Through Your Plan Documents – A lot of us don’t like reading the fine print but it’s important that you understand the details of your Summary of Benefits and Coverage (SBC). Focus on anywhere you find terms like "prosthetics" or "orthotics devices."

·         Talk to BCBS Customer Support – If you are unsure of what your Summary of Benefits and Coverage is saying, you can simply call the number on your insurance card. Talk to customer support and find out the details of your plan’s coverage.

·         Talk to Your Healthcare Provider – The criteria required to qualify for orthotics coverage is pretty clear. Your healthcare provider will be in a good position to let you know if your condition qualifies under the terms stipulated by BCBS.

By the time you are done with these three steps, you should have a pretty good idea if or not you’re covered.

In Conclusion

We understand how expensive orthotics can be, especially the custom-made ones. To make things easier with your BCBS plan, there are some things you need to note.

1.       You will often get a list of in-network suppliers of durable medical equipment (DME). Choosing from this list can help reduce your cost. We mentioned this earlier.

2.       Submit your claims quickly if you happen to make upfront payments for the device. Be sure to include all necessary documents as mentioned earlier.

Just in case you find that your coverage is limited or you're not even covered at all, you may have to consider some other options. You have options like Flexible Spending Accounts (FSAs) or Health Savings Accounts (HSAs). Take a look at them to see if they are better options for you.