Will Medicare Pay for Orthotics?

Overview

While Medicare will cover orthotics up to 80% of the cost, patients must meet very specific requirements before a claim can be approved. Medicare is a federal health insurance program in the United States that focuses on people 65 years and older or younger with certain medical conditions or disabilities, such as End-Stage Renal Disease (ESRD). 

Because custom orthotics can be expensive, many patients cannot afford them, so they look for ways to make them possible. Medicare covers all your orthotic needs, such as orthotic devices for people with diabetic-related foot disease, medically necessary ankle foot orthoses, and knee ankle foot orthoses. 

How Does Medicare Work?

Medicare is generally divided into four parts: Part A, B, C, and D. You typically must pay for Part A and B at once, and they are also regarded as original Medicare.

• Part A (Hospital Insurance): Medicare covers inpatient care in hospitals, nursing facilities, and some health homes. You are not required to pay a premium for Part A if you've paid Medicare taxes for the past ten years.

• Part B (Medicare Insurance): This part covers outpatient care, doctor visits, medical equipment, and some health care. 

• Part C (Medicare Advantage Plans): This plan is offered by private insurers approved by Medicare. It covers Parts A and B and includes additional benefits such as dental, vision, hearing, and prescription drugs.

• Part D (Prescription Drug Coverage): This is offered through private insurance companies, and it helps cover the cost of prescription medications.

How will Medicare Cover Your Orthotics? 

Custom orthotic inserts can cost up to 800 dollars per pair. Because they are custom-made, they are more expensive than the normal over-the-counter pair. While costly, they become more affordable when you factor in Medicare coverage. The beneficiaries must cover 20% of the total cost once their annual deductible has been met, while Medicare will cover the remaining 80% — under these conditions:

1. Medicare Coverage: You must ensure that you have the appropriate Medicare coverage. You can also apply for Medicare coverage in three different periods. The first period, the Initial Enrollment Period (IEP), is three months before your 65th birthday and three months after it ends. The second period, the General Enrollment Period (GEP), is for those who missed the IEP. It is usually held between January 1st to March 31st. The last period, the Special Enrollment Period (SEP), is for specific events, such as losing employer coverage. You can enroll for Medicare on the Social Security website or by visiting the Social Security office.

2. Medicare-approved health provider: Your healthcare provider must be Medicare-approved and agree to the Medicare assignment. This means that the provider must be registered with Medicare and agree to its billing guidelines. They must also agree to be paid directly by Medicare and not charge more than the approved amount.

3. Medicare-approved supplier: The supplier must be certified by Medicare and meet Medicare's standard for Durable Medical Equipment (DME). Medicare will only pay for orthotics if the supplier is enrolled in the Medicare program.

Orthotic Coverage for Medicare

Medicare covers various orthotics, such as braces, insoles, and therapeutic shoes. For coverage to occur, they must be prescribed by a doctor or medical practitioner. Medicare coverage for orthotics includes braces for arm, leg, neck or back, knee, and ankle, as well as custom or prefabricated orthotics.

The orthotic devices also covered by Medicare include:

• A yearly pair of custom-molded shoes and inserts

• A yearly pair of extra-depth shoes

• Two pairs per year of inserts for custom-molded shoes 

• Three pairs per year of inserts for extra-depth shoes

• Shoe modifications

• Legs, arms, neck, and back braces

• Knee and ankle braces.

Can I combine Medicare Coverage with Other Insurance coverages?

Yes, you can. You don't have to rely on Medicare alone as you can combine Medicare with other insurance coverages to make healthcare payments more manageable for you. When you want to combine Medicare and another insurance plan (private or public), a process referred to as coordination of benefits determines who pays first. The insurance provider that pays first is called the primary provider. Once the coverage limit of the primary provider has been reached, the secondary provider pays the cost not covered by the primary provider.

The following are other insurance coverages you can combine with Medicare: 

• Employer or Retiree Coverage: You may still be eligible for health insurance after retirement. When you are 65 or older in companies with over 20 employees, your company's insurance plan pays first. However, if you are less than 20, Medicare pays first.

• COBRA: The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows employees or their families to continue with their insurance plans after losing their jobs or experiencing a life-changing event. Medicare pays first if you have both Medicare and COBRA and are 65 years and older. Medicare also pays first if you have a disability or ALS. However, if you have ESRD, COBRA pays first.

• TRICARE: TRICARE provides healthcare coverage for active and retired military members and their dependents. When you want to combine TRICARE and Medicare, the healthcare insurance provider that will pay first depends on whether or not you are on active duty. If you were on active duty, TRICARE pays first and covers Medicare's deductibles. However, if you were not on active duty, Medicare pays first. If you have the TRICARE for life coverage, TRICARE can decide to pay second.

• Medicaid is a federal and state program that assists low-income people in paying for healthcare. If you want to combine Medicare and Medicaid, Medicaid normally pays last if you have other healthcare insurance plans. Also, if you are an active employee or an annuitant, Medicaid also pays last.

Some Alternatives to Medicare.  

• Medicare Advantage: This is also known as Part C, and it is an alternative to original Medicare. It is a private insurance company plan, although Medicare must approve it.

• Private Health Insurance: Many private insurance plans, whether employer-sponsored or individual, may cover orthotics as part of their benefits, depending on their policies.

• Medicaid: Medicaid is a federal and state-run program for low-income earners that covers orthotics. Medicaid coverage policies vary by state. 

Conclusion

Medicare has strict requirements for orthotic coverage. However, if a patient meets those requirements, Medicare will cover 80% of the cost of obtaining the orthotic device. The patient will have to pay the remaining 20%. When considering Medicare coverage, you should consider the possibility of other insurance coverages that can combined with Medicare. Before choosing or committing to an insurer, conduct thorough research on coverage policies on orthotics and other healthcare devices and services.