Does Medicare cover custom orthotics?
Custom orthotics can be life-changing for individuals suffering from debilitating foot and ankle conditions. By providing tailored support, they help alleviate chronic discomfort and improve mobility. However, with custom orthotics costing between $200 and $800, affordability is a concern for many. This raises two important questions: Does Medicare cover custom orthotics? And what about other insurance plans? Let’s delve into the details to understand your coverage options.
Medicare and custom orthotics coverage
In short, Medicare does cover custom orthotics—but only under specific circumstances. Coverage falls under Medicare Part B, which includes durable medical equipment (DME). Orthotics are part of this category, which also includes braces, orthopedic shoes (if used with a leg brace), and prosthetics like artificial limbs.
Eligibility criteria and coverage details
Medicare provides orthotics coverage for individuals diagnosed with severe foot disease or diabetes. However, patients are responsible for a 20% co-payment. For instance, if your orthotics cost $600, you would pay $120, while Medicare covers the remaining $480.
Under Medicare Part B, beneficiaries are entitled to the following annually:
- One pair of custom-molded shoes
- One pair of custom-molded inserts
- One pair of extra-depth shoes
- Two additional pairs of inserts for custom-molded shoes
- Three additional pairs of inserts for extra-depth shoes
- Shoe modifications in place of inserts
It’s important to consult your healthcare provider and ensure the orthotics supplier is Medicare-approved. Failing to do so could result in unexpected out-of-pocket expenses.
Does private insurance cover custom orthotics?
While orthotics are considered a vital tool for daily mobility and rehabilitation, coverage varies significantly across private insurance plans.
Employer-sponsored plans
Employer-sponsored policies often provide the most consistent coverage. According to recent surveys, 75% of larger employer plans and a similar percentage of smaller plans include “customized bracing” in their benefits. However, the definition of “customized bracing” can be vague, and not all plans explicitly include custom orthotics under this term.
If you’re evaluating or switching jobs, review your policy’s fine print to understand its orthotics coverage. Be prepared for a co-payment, as this is a common requirement.
Marketplace policies
Health insurance policies purchased through the Affordable Care Act (ACA) Marketplace must cover ten essential health benefit categories. One of these categories, “rehabilitative and habilitative services and devices,” often includes custom orthotics.
These services are designed to help individuals with injuries, disabilities, or chronic conditions recover physical or mental skills. Custom orthotics often meet these criteria, making them eligible for coverage under many Marketplace plans. However, state-specific interpretations of ACA guidelines can influence what is covered. If orthotics are not explicitly included in your state’s essential benefits, finding a policy that covers them may prove challenging.
Final thoughts
While custom orthotics can significantly improve quality of life, coverage depends on your insurance plan or Medicare eligibility. Under Medicare Part B, orthotics are covered for individuals with severe foot disease or diabetes, but a 20% co-payment applies. Employer-sponsored insurance plans are the most likely to include orthotics as part of their benefits, while Marketplace policies vary based on state interpretations of the ACA.
To avoid surprises, it’s essential to verify your coverage before proceeding. Speak with your healthcare provider or insurer to understand your options. For personalized guidance, reach out to our team—we’re here to help you navigate funding for your custom orthotics.
