Are Custom Orthotics Covered by Medicare?

Custom orthotics can be a significant support for various medical conditions, prompting many to inquire about Medicare coverage. Medicare provides coverage for certain orthotic devices when medically necessary. Understanding the specific criteria and processes is essential for beneficiaries. This guide clarifies how Medicare addresses orthotics, detailing covered types, financial obligations, and necessary steps.

Covered Orthotics and Medical Necessity

Medicare covers specific types of orthotic devices considered medically necessary for treating certain conditions. Orthotics, also called orthoses, are external devices designed to support a weak or deformed body part or restrict motion in an injured or diseased area. These devices typically fall under the Durable Medical Equipment (DME) benefit category. Therapeutic shoes and inserts for diabetics are covered under a separate Part B benefit. For coverage, an item must be reasonable and necessary for diagnosis or treatment of an illness or injury, or to improve functioning of a malformed body member.

Coverage extends to custom-molded shoes and inserts, as well as extra-depth shoes, particularly for individuals with diabetes who have severe foot disease. Medicare may cover one pair of custom-molded shoes and inserts, or one pair of extra-depth shoes, annually for these beneficiaries. Additionally, two extra pairs of inserts for custom-molded shoes or three extra pairs for extra-depth shoes may also be covered each calendar year. These provisions aim to prevent or treat diabetic foot ulcers.

Beyond diabetic foot care, Medicare also covers medically necessary ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs), which are types of braces. These braces must be rigid or semi-rigid devices used to support, immobilize, or treat muscles, joints, or portions of the skeleton that are injured, deformed, or too weak. Conditions necessitating such coverage include severe arthritis, severe foot issues not related to diabetes, or post-surgical recovery. A qualified medical doctor must prescribe these orthoses, and medical necessity must be clearly documented.

Understanding Medicare Coverage Rules

Orthotics are primarily covered under Medicare Part B, the medical insurance component of Original Medicare. Part B covers outpatient medical care, including doctor visits, medical supplies, and durable medical equipment. For coverage, orthotics must be prescribed by a Medicare-enrolled doctor or other healthcare professional.

Beneficiaries are responsible for certain out-of-pocket costs under Medicare Part B. An annual deductible must be met before Medicare pays its share. For 2025, the annual Part B deductible is $257. Once satisfied, Medicare typically covers 80% of the Medicare-approved amount for the orthotic device, with the beneficiary paying the remaining 20% coinsurance. For example, a $600 orthotic, after the deductible is met, results in Medicare paying $480 and the beneficiary paying $120.

It is important to obtain orthotics from Medicare-enrolled suppliers who accept assignment. Accepting assignment means the supplier agrees to accept the Medicare-approved amount as full payment for the service or item. This prevents the supplier from billing the beneficiary for more than the Medicare deductible and coinsurance. If a supplier does not accept assignment, they can charge more than the Medicare-approved amount, leaving the beneficiary responsible for the difference, known as “excess charges.”

Medicare Advantage Plans (Part C) are another option, provided by private insurance companies approved by Medicare. These plans must cover at least everything Original Medicare covers, including medically necessary orthotics. However, Medicare Advantage Plans may have different cost-sharing rules, such as varying deductibles, copayments, or coinsurance amounts. They may also require using a network of preferred providers or suppliers. Beneficiaries with a Medicare Advantage Plan should check their specific plan details for orthotics coverage.

Steps to Get Your Orthotics

Obtaining orthotics through Medicare involves a clear process beginning with your healthcare provider. The process begins with a written prescription from a Medicare-enrolled doctor or other qualified healthcare professional. This prescription must state the medical necessity for the orthotic device and how it addresses your condition. For therapeutic shoes and inserts for diabetes, the doctor treating your diabetes must certify the need for these items.

Once you have a prescription, find a Medicare-approved supplier for your orthotics. Medicare mandates that orthotic devices must be obtained from suppliers enrolled in the Medicare program. Resources like Medicare’s website offer a supplier directory to help locate approved providers. Confirm the chosen supplier accepts assignment to limit out-of-pocket costs to the deductible and coinsurance.

After obtaining orthotics from an approved supplier, the supplier is typically responsible for submitting the claim to Medicare on your behalf. Medicare processes the claim and sends an Explanation of Benefits (EOB) to the beneficiary. This document details what Medicare paid, the amount applied to your deductible, and your remaining coinsurance responsibility. The supplier will then bill you for any deductible amount not yet met and the 20% coinsurance. Medicare may also require prior authorization for certain orthotic devices, meaning additional documentation might be needed before coverage is approved.