Receiving a pair of custom orthotics is life-changing. No more painful walking. No more chronic discomfort. You’ll experience sudden relief from otherwise debilitating foot and ankle conditions through these devices. Given the remarkable effects of orthotics, we’re asked two common questions:
Does Medicare cover custom orthotics?
Does insurance cover custom orthotics?
With the cost of custom orthotics ranging from $200 to $800, many patients can ill-afford this expense. That’s why it’s so important to know what’s covered; otherwise, the alternative is a $20 pair of off-the-shelf orthotics from the drug store.
What is orthotics?
An orthotic or orthoses is a rigid or semi-rigid device used to support, align, prevent, or correct deformities; protect body function; assist a dysfunctional joint; and improve the function of movable body parts, according to BlueCross BlueShield.
We commonly think of shoe inserts as the only form of orthotics. However, other types of orthotics include:
Orthotic, orthopedic, or therapeutic shoes
Foot pads
Leg, arm, back, and shoulder braces
Spring-loaded orthotic devices
Custom molded foot orthotics
Trusses
We should differentiate between orthotics and prosthetics. Where the former assists the movement or function of existing body parts, the latter acts as a wholesale replacement. While the category of orthotics is broad, we’re only considering custom molded foot orthotics below.
Does Medicare cover custom orthotics?
In short, yes.
Medicare covers orthotics shoes and inserts for specific conditions. Not everyone is eligible for Medicare to cover the cost of the orthotics – and in many cases, you may need to pay a small co-payment (20%). For example, if the orthotics cost $600, you’d pay $120, and Medicare covers the remaining $480.
The specific conditions covered by Medicare include severe foot disease and diabetes. Orthotics are covered under Part B. Technically, orthotics are considered part of the durable medical equipment (DME) bracket, including:
Bracing for ankle, foot, knee, back, neck, spine, hand, wrist, and elbow
Orthopedic shoes as part of a leg brace
Prosthetic devices like artificial limbs
Other orthotics are not considered DME but are still part of Medicare B. Under Medicare Plan B, you will be covered for the following each year:
One pair of custom-molded shoes
One pair of custom-molded inserts
One pair of extra-depth shoes
Two pairs of additional inserts for custom-molded shoes
Three pairs of additional inserts for extra-depth shoes
Modifications for custom shoes instead of inserts
Does insurance cover custom orthotics?
Given their importance to daily function, you may imagine orthotics are universally covered under your health insurance plan. That’s not always the case. Despite being a cost-effective podiatric intervention, some providers and health plans don’t extend coverage that far.
Employer-sponsored or job-based policies are highly variable. Nevertheless, according to a recent survey, 75% of larger private employer plans covered “customized bracing;” the same is true of smaller private employer plans.
The question is if custom orthotics are always covered by the term “customized bracing.” If you’re planning to switch jobs, you’ll want to find out precisely what’s included and how the provider defines orthotics under their plan. You may still be charged a co-payment – that’s normal.
Marketplace policies are regulated by the Affordable Care Act, which requires plans to cover ten categories of essential health benefits; “rehabilitative and habilitative services and devices” is one of these categories.
As health.gov explains, rehabilitative and habilitative services and devices “help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.”
Luckily, many custom orthotics meet this description – and so are covered by most marketplace healthcare plans. Nevertheless, clarifying this point with a provider is still sensible to better understand where they draw the line. Indeed, if your state doesn’t consider orthotics within the description, you’ll struggle to find any other local policies that do either.
Final thoughts
You should never assume that your medical plan or Medicare covers orthotics. In most circ*mstances, some or all of the cost of the custom orthotic is covered. However, you may still need to contribute some money towards the final price.
Medicare B covers 80% of the orthotics’ cost, so long as you have either diabetes or severe foot disease. Under insurance plans, it largely depends on how your local state interprets the categories covered by the Affordable Care Act. Employer-sponsored policies are the most likely to cover orthotics, with 70-75% of all employer policies including it as standard.
If you need orthotics, please speak to our team about your funding options – we’re more than happy to discuss your situation.
