Does Medicare Cover Shoe Inserts and Orthotics?
Understand Medicare's coverage for orthotics and foot inserts. Learn eligibility, medical necessity, and financial responsibilities.
Medicare is a federal health insurance program for eligible individuals. It primarily serves people age 65 or older, and younger individuals with certain disabilities or specific medical conditions like End-Stage Renal Disease. The program helps manage the financial burden of medical care, which often increases with age or the onset of chronic health issues. Medicare is structured into different parts, each covering various types of services and care.
General Medicare Coverage for Foot-Related Medical Equipment
Medicare generally covers durable medical equipment (DME), prosthetics, and orthotics under Part B, which addresses outpatient medical care. DME refers to reusable medical equipment prescribed for home use, such as walkers, wheelchairs, and oxygen equipment. Prosthetics are devices that replace a missing body part or function, such as artificial limbs.
Orthotics are rigid or semi-rigid devices designed to support, align, prevent, or correct deformities, or to restrict motion in a diseased or injured body part. For any of these items to be covered, Medicare requires them to be medically necessary, meaning they are needed to diagnose or treat an illness or injury. This medical necessity must be documented and prescribed by a Medicare-enrolled physician.
Specific Conditions for Orthotic Insert Coverage
Medicare Part B specifically covers certain orthotic inserts, particularly custom-molded options, when medically necessary for severe foot conditions. This coverage applies to individuals with diabetes and severe diabetes-related foot disease. The goal of such coverage is to prevent serious complications like ulceration or amputation.
For individuals with diabetes, Medicare may cover one pair of custom-molded shoes and inserts, or one pair of extra-depth shoes, annually. Coverage also extends to additional inserts or shoe modifications. Custom-molded shoes are covered when a foot deformity cannot be accommodated by extra-depth shoes. Medicare covers custom-molded inserts, not generic, off-the-shelf shoe inserts, as these are considered comfort items rather than medically necessary devices.
Required Steps for Coverage
A physician’s order or prescription is required, stating the medical necessity and the precise type of custom-molded orthotics needed. The physician treating the medical condition must certify the necessity for the items. Detailed documentation of the qualifying medical condition, functional limitations, and how the orthotic device will improve the patient’s condition must be included in the patient’s medical records.
Orthotics must be purchased from a supplier enrolled in Medicare. Beneficiaries should confirm that both their prescribing doctor and the supplier accept Medicare assignment to ensure coverage. The Medicare-approved supplier will bill Medicare directly for the orthotics. The beneficiary may need to sign an Assignment of Benefits form, which authorizes Medicare to pay the supplier directly.
Financial Responsibility
Even when orthotic inserts are covered by Medicare Part B, beneficiaries have financial obligations. After the annual Part B deductible is met, Medicare pays 80% of the Medicare-approved amount. The beneficiary is responsible for the remaining 20% coinsurance. For example, for a $600 orthotic, if the deductible is met, the beneficiary would pay $120. The Part B deductible for 2025 is $257.
If a beneficiary has a Medigap policy (Medicare Supplement Insurance) or a Medicare Advantage Plan (Part C), these private insurance plans might cover some or all of the coinsurance and deductibles. If the orthotic inserts do not meet Medicare’s coverage criteria, the beneficiary will be responsible for 100% of the cost. Additionally, if a supplier does not accept Medicare assignment, the beneficiary may be required to pay the full amount upfront.