Medicare Part B Coverage for Orthotics
Medicare Part B is the primary source of coverage for orthotics, classifying them under Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). To be covered, the orthotic device must be deemed medically necessary by a qualified, Medicare-enrolled physician. The specific conditions and covered items differ, with more extensive coverage available for seniors with diabetes.
Foot Orthotics for Diabetic Seniors
For seniors with diabetes and severe foot disease, Medicare Part B offers specific benefits for therapeutic shoes and inserts. This is because diabetic neuropathy and poor circulation can lead to severe complications, and therapeutic footwear is a critical preventive measure.
Annually, Medicare will cover one of the following options:
- One pair of custom-molded shoes and two additional pairs of inserts.
- One pair of extra-depth shoes and three pairs of inserts.
In addition to footwear, Medicare may also cover modifications to therapeutic shoes instead of inserts. For this coverage to apply, the certifying physician managing the patient's diabetes must document the need and provide a prescription.
Braces for Ankle, Knee, and Back
Beyond diabetic footwear, Medicare Part B covers various other orthotic braces when medically necessary. These devices must be rigid or semi-rigid and are intended to support a weak body part, correct an irregularity, or limit movement in an injured or diseased area. Common examples include:
- Ankle-foot orthoses (AFOs)
- Knee-ankle-foot orthoses (KAFOs)
- Spinal braces
- Hand and wrist braces
As with foot orthotics, a Medicare-enrolled doctor must prescribe the brace, and it must be supplied by a Medicare-approved provider.
Understanding Your Costs
The amount a senior pays for Medicare-covered orthotics involves a few key factors: the Part B deductible and the 20% coinsurance.
The Part B Deductible
Before Medicare begins to pay its share, you must first pay the annual Part B deductible. The deductible amount changes each year. For 2025, the deductible is $257. Once you meet this amount, Medicare will start covering its portion of the costs for all Part B services, including orthotics.
The 20% Coinsurance
After your deductible is met, you are responsible for a 20% coinsurance for the Medicare-approved amount of the orthotic device. This means Medicare covers the remaining 80%. For example, if a custom orthotic has a Medicare-approved amount of $600, your share would be $120 (20%), and Medicare would pay $480.
The Importance of Accepted Assignment
To ensure you only pay the 20% coinsurance (after your deductible), it is crucial to use a supplier who accepts Medicare assignment. If a supplier does not accept assignment, they can charge you more than the Medicare-approved amount, leaving you responsible for the extra costs.
Original Medicare vs. Medicare Advantage
While Original Medicare (Parts A and B) provides standard coverage, costs and benefits can differ for seniors with a Medicare Advantage (Part C) plan.
| Feature | Original Medicare (Part B) | Medicare Advantage (Part C) |
|---|---|---|
| Coverage Base | Provides standard, government-regulated coverage for medically necessary orthotics. | Must offer at least the same level of coverage as Original Medicare. |
| Cost-Sharing | 20% coinsurance for the Medicare-approved amount after meeting the annual Part B deductible. | Costs can vary by plan. You may have a different copayment, coinsurance, or deductible structure. |
| Network | You can use any Medicare-enrolled provider or supplier nationwide. | Typically requires you to use providers and suppliers within the plan's network, which may be more limited. |
| Additional Benefits | No additional benefits for routine foot care or other non-medically necessary items. | Some plans may offer extra benefits for foot care or other orthotic needs not covered by Original Medicare. |
How to Get Orthotics Covered
Following a specific process is key to ensuring Medicare covers your orthotics.
1. Get a Medical Evaluation and Prescription: Visit a Medicare-enrolled physician (an MD or DO) or podiatrist who will evaluate your condition and confirm the medical necessity for orthotics. The doctor will provide a detailed prescription.
2. Find a Medicare-Approved Supplier: Use the Medicare Supplier Directory on Medicare.gov to find a DMEPOS supplier that is enrolled in Medicare and accepts assignment.
3. Confirm Your Coverage and Costs: Before receiving the item, verify with your supplier that they accept assignment. They should provide a cost estimate that outlines your potential out-of-pocket expenses.
4. Receive the Orthotic Device: The supplier will furnish and fit the device. For diabetic shoes and inserts, a final fitting and assessment are required upon delivery.
5. Submit the Claim: The supplier is usually responsible for submitting the claim to Medicare on your behalf.
Common Reasons for Denial and How to Appeal
Sometimes, a claim for orthotics may be denied. Common reasons include insufficient documentation, a prescription from a non-qualifying provider, or the device not meeting medical necessity criteria. If your claim is denied, you can appeal the decision. The first step is to review your Medicare Summary Notice (MSN) for the reason for denial and then follow the instructions for filing an appeal. Collecting supporting medical documentation and working with your doctor can help strengthen your appeal.
Conclusion
For seniors requiring orthotics, Medicare provides significant coverage, typically paying 80% of the Medicare-approved amount after the Part B deductible is met. However, this coverage is not automatic. The process requires a medically necessary prescription from a Medicare-enrolled doctor and using a supplier that accepts Medicare assignment. Paying attention to these details and understanding your plan can significantly reduce your out-of-pocket costs. Seniors with diabetes receive specific annual benefits for therapeutic footwear, while others may be covered for braces and other devices for various medical conditions. By following the correct procedures and being aware of the costs involved, seniors can ensure they get the necessary orthotic support covered by their Medicare benefits.
