Does Medicare Cover Orthotics?
- Does Medicare cover orthotics? It depends on factors such as medical necessity and your individual plan. Find out more.
Usually considered part of the durable medical equipment (DME) benefit, orthotics are covered by Medicare in certain situations. Individuals covered by original Medicare can expect to pay 20% of the allowable rate for orthotics unless they are also enrolled in a supplement plan designed to cover their out-of-pocket expenses.
Learn about the types of orthotics Medicare may cover and discuss your eligibility for this benefit with your provider before services are rendered.
How Does Medicare Cover Orthotics for Your Feet?
Falling under the Medicare Part B, or outpatient medical benefit, foot orthotics are covered if you have been diagnosed with diabetes and severe diabetic foot disease. In this case, original Medicare covers one of the following per calendar year:
- 1 pair of custom-molded shoes and inserts (and two additional pairs of inserts) or
- 1 pair of extra-depth shoes (and three additional pairs of inserts)
Coverage includes the furnishing and fitting of either orthotic option. In certain situations, Medicare may cover modifications to a foot orthotic instead of inserts.
What Is the Difference Between Custom-Molded Shoes and Extra-Depth Shoes?
Custom-molded orthotics are molded to your individual foot. Comparatively, extra-depth shoes are not molded to your unique foot shape. Instead, extra-depth shoes may provide enhanced padding, are available in a variety of widths and are designed to reduce or eliminate the irritation that can occur when parts of your foot rub against the interior of a shoe.
Does Medicare Cover Orthotics for Plantar Fasciitis?
Characterized by intense heel pain due to inflammation of the plantar fascia, plantar fasciitis is a leading cause of visits to the podiatrist each year. Medicare's prescription foot orthotic policy specifies that, in order to be eligible for the benefit, an individual must be diagnosed with diabetes and severe diabetic foot disease.
Your Medicare-approved provider can request a pre-determination of benefits if he or she feels you have a medically necessary reason (other than severe diabetic foot disease) to wear foot orthotics.
Medicare Advantage (Part C) & Orthotics: What is Covered?
If you are enrolled in a Part C, or Medicare Advantage plan, the private insurer responsible for administering the plan may offer enhanced benefits beyond Medicare's coverage for foot orthotics. If you're unsure what is covered, you should speak with your provider and refer to your plan's benefits coverage details.
Does Medicare Cover Orthotics Over-the-Counter (OTC)?
In general, OTC orthotics are not covered under original Medicare. This is because, by nature, foot orthotics are customized to your specific foot needs and not available in an OTC option. Orthotics are typically prescribed by a Medicare-approved podiatrist and supplied via a DME company or orthotics specialist.
However, if you're enrolled in a Medicare Advantage (Part C) plan and do not meet the coverage criteria for prescription orthotics, you may be able to find an OTC foot insert to suit your needs. Because Medicare Advantage plans typically offer enhanced benefits, such as dental, vision or hearing, not covered by traditional Medicare, you may have an annual or quarterly OTC benefit that can help pay for OTC shoe inserts.
What Are My Next Steps?
If you feel you may qualify for prescription orthotics, your next step is to speak with your provider or Medicare to verify coverage. Generally, the following criteria must be met for Medicare to cover orthotics:
- Prescribed by a Medicare-approved provider
- Supplied by a Medicare-approved provider
- Orthotics must be medically necessary
- Must have a Medicare-approved diagnosis, such as severe diabetic foot disease
For specific questions about your plan's coverage, always refer to your benefits paperwork. If you are enrolled in original Medicare, contact Medicare with any questions about orthotics coverage prior to paying out-of-pocket for the service. Individuals with Part C coverage will need to contact their insurance carrier for complete benefit details and eligibility.