Injuries like sprains and tears in the ligaments, tendons, muscles, and joints can lead to wearing orthotic braces, but these conditions can also develop over years or decades. Here’s what Medicare will cover for orthotics to correct these ailments.
What are orthotics?
Orthotic braces support, align, relieve, and correct problems of different parts of the body like the ankle, knee, and back. The term orthotics generally refers to corrective shoes and shoe inserts that offer support to correct different conditions that can cause pain or discomfort.
Orthotics can help with conditions like:
- Back pain
- Flat feet
- Hammer toes
- High arches
- Plantar fasciitis
- Sports injuries
What are the different orthotics?
The three types of orthotics are:
- Over-the-counter (OTC). You can purchase these off the shelf at a drugstore and cut them to fit in your shoe.
- Kiosk-generated. Some drug stores may have a machine that asks you to stand on a pad which then measures your foot size, arch, and weight distribution. It will then recommend a brand and size based on the measurements.
- Prescription. Prescribed from an orthopedic specialist, the doctor will take an impression of your foot and order a custom-made shoe or insert for you after assessing your lifestyle, level of activity, medical condition, height, foot rigidity and flexibility, and more.
The difference between these orthotics can be compared to OTC vs. prescription glasses; the more severe the condition, the more likely it is you will need a prescription orthotic shoe or insert.
Medicare Part B covers custom-made orthotic shoes and orthotic inserts as durable medical equipment (DME) as long as they are:
- Deemed medically necessary by a doctor,
- Prescribed by a Medicare-approved doctor, and
- Purchased from a Medicare-approved DME supplier.
Medicare also covers the following orthotic braces under the same conditions:
- Braces for the ankle, foot, knee, hand, elbow, wrist, back, neck, and spine;
- Orthopedic shoes as part of a leg brace; and
- Prosthetic devices like artificial limbs.
Medicare coverage for diabetes orthotics
Due to decreased blood circulation and nerve sensitivity, it’s common for people with diabetes to have foot problems. If the feet are not properly protected, a simple cut or wound could eventually lead to an amputation.
If you have diabetes, Medicare will also cover the furnishing and fitting of one of the following within a calendar year:
- One pair of custom-made shoes and orthotic inserts, or
- One pair of extra deep shoes.
The following are also covered for diabetes patients within a calendar year:
- Two additional pairs of inserts for custom-made shoes, and
- Three pairs of inserts for extra deep shoes.
If you meet all of the aforementioned qualifications, Medicare will cover 80 percent of the cost, while you will be responsible for the remaining 20 percent. The Part B deductible also applies.
Prices can range from tens of dollars for an OTC orthotic, to hundreds of dollars for a custom-made, prescription orthotic.
Prices will also vary based on your Medicare plan, the Medicare supplier from which you buy the orthotic, and the type of orthotic you need.
Before going to the doctor for a prescription orthotic, it is recommended to have your feet professionally measured and buy a pair of high-quality, supportive shoes to see if that will help the problem. Many adults haven’t had their feet measured since they were in high school or middle school, but the size and width of our feet can change over the span of a lifetime.
Prescription orthotics can be expensive, so it is recommended to start with new shoes, then progress to an OTC/kiosk-generated orthotic before you see a doctor for a prescription.