Does Medicaid Cover Orthotics?

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  • Does Medicaid cover orthotics? It depends. While some states cover orthotic devices, others don't. Read on to learn more about orthotics and Medicaid coverage.

Orthotic devices, also known as orthotics, relieve foot and ankle pain by keeping the feet aligned correctly. Although it's possible to buy inexpensive, over-the-counter orthotics, your doctor may recommend custom devices. Custom orthotics are made by making casts of your feet and using them to produce supportive devices that fit perfectly. If you have Medicaid, you may be wondering if your plan covers orthotics. So, does Medicaid cover orthotics for its enrollees? It depends on where you live.

Does Medicaid Cover Orthotics in Full?

The Medicaid program is a joint effort between the federal government and individual U.S. states. At the federal level, the Centers for Medicare & Medicaid Services sets rules that all states must follow in administering their Medicaid programs. One of the most important rules is that every state must cover a set of "mandatory benefits" for its Medicaid enrollees. Mandatory benefits include hospital care, laboratory services, home health care and family planning services.

States are allowed to cover additional services, known as optional benefits, but what's covered depends on where you live. As of 2021, 44 states and the District of Columbia cover orthotics as part of their optional benefits packages. If you live in Mississippi, orthotics aren't covered under your state's Medicaid plan. Illinois, Iowa, Nevada, New York and South Carolina may cover orthotics, but the information isn't available to the public. You'd have to call the state Medicaid office to inquire about coverage.

The Average Cost of Orthotics

Custom orthotics are much more expensive than the over-the-counter kind, but they're also more effective. Without insurance, it may cost anywhere from $200 to $800 to have custom orthotics made. It could cost even more if your doctor orders a foot X-ray or performs other services before deciding that wearing orthotics is the best course of action. Over-the-counter orthotics may cost as little as $10 per set, but remember that they're not customized for your feet, so they may not help with proper foot alignment.

Does Medicaid Cover Orthotics Without a Copay?

State Medicaid programs are allowed to charge nominal copays for some services, including orthotics. In most states, the copay is a flat fee, but some states require enrollees to pay for a certain percentage of the cost. For example, South Dakota requires enrollees to pay 5% of the Medicaid-approved amount. Some states set their copays based on each enrollee's financial situation. In Montana, enrollees who are at or below 100% of the Federal Poverty Level pay a $4 copay, while enrollees above the Federal Poverty Level pay 10% of the cost. Many states require no copays for orthotics, including Arizona, California, Connecticut, Hawaii, Louisiana, Massachusetts and Vermont.

Custom Orthotics vs. Over-the-Counter Orthotics

If you've ever seen a rack of orthotics at your local pharmacy, you may think that their only purpose is to give your feet a little extra support. That's not the case with custom orthotics. Unlike inexpensive orthotics that can be bent in half without much effort, custom devices are somewhat rigid. They're designed to correct deformities, keep the feet and ankles in proper alignment, improve joint function and protect the feet and ankles from stress.

Non-Medicaid Insurance Coverage for Orthotics

If you have Medicaid and someone in your family has a different insurance plan, they may or may not have coverage for orthotics. Many health insurance plans cover durable medical equipment, but not all of them offer the same level of coverage. A Bronze plan from the Health Insurance Marketplace, for example, typically has a 60/40 coinsurance split, meaning the plan pays 60% of the approved amount and the covered individual pays the other 40%. Platinum plans have a 90/10 split, which means the covered individual would only have to pay 10% of the cost. Employer-sponsored plans also offer different levels of coverage based on location and plan type.

The Patient Protection and Affordable Care Act doesn't specifically state that Marketplace plans must cover orthotics; it simply states that each plan must cover rehabilitative devices. Therefore, where you live can affect whether you're covered for orthotics under a Marketplace plan. If your state doesn't classify orthotics as a type of rehabilitative device, you may have to pay the full cost on your own.

Does Medicare Cover Orthotics?

Anyone in your household who has Medicare may be able to get coverage under Medicare Part B. For Medicare to pay for orthotics, the devices must be medically necessary to treat an illness, injury or disease, and the enrollee must get the orthotics from a doctor or provider who accepts Medicare assignment. Medicare enrollees typically pay 20% of the approved amount for orthotics when those orthotics are purchased from a participating supplier.

Determining Coverage for Orthotics

Does Medicaid cover orthotics? Now that you know that the answer depends on where you live, it's important to know how to determine if your specific plan covers orthotic devices. If you're not sure, call your state's Medicaid office and ask about coverage for prosthetics, orthotics and similar services. When you enrolled in Medicaid, you may have received a booklet or packet of paperwork with coverage details. Review the information carefully to determine if orthotics are covered.

If you have a private health insurance plan, look at your plan's summary of benefits and coverage (SBC). The SBC won't list every possible service covered under the plan, but it will tell you if the plan covers durable medical equipment. Reviewing the SBC can also help determine how much you can expect to pay in copays, coinsurance and other out-of-pocket costs.

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