Does Medicare Pay for Orthotics? Coverage Rules

Understanding Medicare’s coverage for orthotics, external devices designed to support or correct body parts, is important for beneficiaries. This article clarifies Medicare’s provisions for orthotics, offering guidance on eligibility, types of covered devices, and financial responsibilities.

Medicare’s Orthotic Coverage Basics

Medicare’s coverage for orthotics primarily falls under Medicare Part B, which addresses outpatient medical services and supplies. Orthotics are often classified as Durable Medical Equipment (DME). DME includes items used for a medical purpose, that can withstand repeated use, and are generally not useful to someone who is not sick or injured. To qualify for coverage, a qualified healthcare provider must deem the orthotic medically necessary.

Medical necessity means the device is required for diagnosing or treating an illness or injury, or to improve the functioning of a malformed body part. A physician must prescribe the orthotic, ensuring it directly addresses a specific medical condition. The orthotic must also be obtained from a Medicare-enrolled supplier who accepts Medicare assignment, agreeing to the Medicare-approved amount as full payment.

Specific Orthotic Devices and Coverage Rules

Medicare Part B covers various orthotic devices when medically necessary. This includes braces supporting weakened or injured body parts such as the leg, arm, back, neck, knee, and ankle. Devices like Ankle-Foot Orthoses (AFOs) and Knee-Ankle-Foot Orthoses (KAFOs) are covered under the brace benefit. These braces can be custom-fabricated or off-the-shelf, with coverage dependent on medical justification and fitting requirements.

For certain conditions, Medicare provides specific coverage for therapeutic shoes and inserts. Individuals with diabetes and severe diabetes-related foot disease may qualify for one pair of custom-molded shoes and inserts or one pair of extra-depth shoes each calendar year. This coverage also extends to two additional pairs of inserts for custom-molded shoes or three additional pairs of inserts for extra-depth shoes annually. Modifications to custom shoes can also be covered in lieu of inserts. While some custom foot orthotics are covered under these diabetic provisions, general custom inserts for arch support or comfort are not covered by Original Medicare unless they are an integral part of a leg brace.

Steps to Obtain Medicare-Covered Orthotics

Initiating the process for Medicare-covered orthotics begins with a consultation with a healthcare provider. The physician assesses the individual’s condition, determines the medical necessity of the orthotic device, and issues a written prescription or order. This prescription, often called a Standard Written Order (SWO), must clearly describe the item, order date, beneficiary’s information, and supporting medical documentation.

Once the prescription is obtained, select a Medicare-approved supplier. These suppliers are enrolled in the Medicare program and adhere to its regulations. Beneficiaries can locate approved suppliers through Medicare’s official website or by contacting Medicare directly. The chosen supplier will then work with the healthcare provider to gather additional documentation, such as medical records, to substantiate the device’s medical necessity.

The Medicare-approved supplier generally submits the claim directly to Medicare on behalf of the beneficiary. If coverage for a specific device is uncertain, the supplier may ask the beneficiary to sign an Advance Beneficiary Notice of Noncoverage (ABN). An ABN informs the beneficiary that Medicare might not cover the item or service, making them responsible for payment if Medicare denies the claim. After the claim is processed, Medicare sends an Explanation of Benefits (EOB) detailing what was paid and any remaining financial responsibility.

Understanding Your Out-of-Pocket Costs

When Medicare Part B covers orthotic devices, beneficiaries are responsible for out-of-pocket costs. After meeting the annual Medicare Part B deductible ($257 in 2025), individuals generally pay 20% of the Medicare-approved amount for the orthotic. This 20% is known as coinsurance. For example, if an orthotic costs $600 and the deductible has been met, the beneficiary pays $120, with Medicare covering the remaining $480.

For individuals enrolled in a Medicare Advantage (Part C) plan, the cost-sharing structure for orthotics may differ from Original Medicare. Medicare Advantage plans must cover at least the same benefits as Original Medicare, but they often have different deductibles, copayments, or coinsurance amounts. Beneficiaries with these plans should consult their plan documents or contact their plan provider directly to understand their financial responsibilities for orthotic devices.

Supplemental insurance policies, such as Medigap plans, can help cover some or all of the out-of-pocket costs associated with Original Medicare. Depending on the specific Medigap plan, it may cover the Part B deductible, copayments, and coinsurance amounts for Medicare-approved orthotics, reducing the beneficiary’s financial burden.