Does Medicare cover orthotics?

Do you need orthotics treatment? Orthotics is a medical specialty that involves external devices used to modify the structural and functional characteristics of the skeletal and neuromuscular system. In plain English, this means that an orthotist is a medical clinician who prescribes and manages orthotic devices to assist patients with limb loss or loss of functionality. Orthotic devices may include braces, splints, hinges, shoe inserts, and a wide variety of other mechanical aids. These aids assist movement, reduce weight bearing forces, ease the rehabilitation of fractures, and correct the shape or function of the body to ease movement and reduce pain. Orthotic devices are also used to treat conditions ranging from cerebral palsy to spinal cord injuries to strokes.

Medicare offers limited coverage options for orthotic devices, which can also include prosthetic limbs in some cases. Medicare Part B may cover artificial limbs and eyes as well as braces for arms, legs, back, or neck. It can also cover breast prostheses following a mastectomy. Part B also covers orthopedic shoes if they are a medically necessary companion treatment to a Medicare-approved orthotic leg brace. Prosthetic shoes may be covered by Medicare Part B if they are an integral part of treatment for patients with a partial foot amputation.

Medicare Part B also covers therapeutic shoes or inserts for diabetic patients who are suffering from severe diabetic foot disease. The shoes or inserts must be provided by a qualified individual, which can be:

  • a podiatrist
  • an orthotist
  • a prosthetist
  • a pedorthist

Medicare covers the furnishing and fitting of either one pair of custom-molded shoes and inserts or one pair of extra depth shoes per calendar year. Additionally, Medicare covers two extra pairs of inserts per calendar year for custom shoes and three pairs of inserts each year for extra depth shoes.

Qualifying for coverage

To qualify for coverage under Medicare Part B, you must obtain an orthotics prescription from your doctor or podiatrist. You must also get the orthotic devices from a supplier that is enrolled in Medicare. When it comes to costs, you’ll first need to pay your Medicare Part B deductible. After that, Medicare will typically pay 80% of the approved cost for orthotics equipment. You will need to pay the remaining 20%. Be sure to consult with your doctor or orthotic specialist to determine what equipment is right for you. Also you should know that Medicare occasionally values the equipment at less than the actual purchase price, which means that you will be responsible for paying the difference.

If, after consultation with your doctor, you determine that Medicare’s Part B coverage does not meet your orthotic needs, you may opt for Medicare Part C coverage (sometimes called a Medicare Advantage Plan). Part C offerings usually include extra services when compared to Part B coverage, which may help to offset the cost of various orthotic devices. Co-payments for Part C may differ from those of Part B, so be sure to discuss your particular needs with your doctor and a Medicare specialist. You can call Medicare directly at 1-800-633-4227.

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