Medicare covers the furnishing and fitting of therapeutic shoes and inserts, called orthotics, for diabetes and severe diabetes-related foot disease. It also covers medically necessary ankle-foot orthoses and knee-ankle-foot orthoses.
An orthosis is an external device, such as a brace or splint, that supports a body part or function. The word “orthoses” is the plural form of “orthosis.”
Medicare also covers some additional items and services for people with diabetes and severe diabetes-related foot disease, such as shoe modification and additional pairs of inserts.
This article explores Medicare coverage for orthotics in more detail, including who can prescribe them and what they might cost.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare covers several services and medical devices for individuals who have diabetes and severe diabetes-related foot disease. This
Each calendar year, Medicare Part B covers the furnishing and fitting of either one pair of extra-depth shoes or one pair of custom-molded shoes and inserts. In the same time period, it also covers three pairs of inserts for extra-depth shoes and two additional pairs of inserts for custom-molded shoes.
In addition, Medicare can cover shoe modifications instead of inserts.
People should note that the healthcare professional who treats a person’s diabetes must certify that they need therapeutic shoes or inserts.
Orthoses
Medicare covers ankle-foot orthoses and knee-ankle-foot orthoses under the braces benefit, which falls under Medicare Part B.
The orthosis must be a rigid or semi-rigid device, used to support a weak or irregularly formed body part or to restrict or eliminate motion in a diseased or injured part of the body. If the orthosis does not meet these criteria, it is not eligible for coverage under Medicare.
Medicare Part A may also cover ankle-foot orthoses and knee-ankle-foot orthoses, in certain cases.
Payment for these devices is included in the payment to a hospital or skilled nursing facility (SNF) if:
- The orthosis is provided to a beneficiary prior to an inpatient hospital admission or an SNF stay covered by Part A.
- The medical necessity for the orthosis begins during the hospital or SNF stay, such as after knee, ankle, or foot surgery.
Payment for these devices is also included in the payment to a hospital or a Part A-covered SNF stay if:
- The orthosis is provided to a beneficiary during an inpatient hospital or Part A-covered SNF stay prior to the day of discharge.
- The beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.
People must not submit a claim to the durable medical equipment (DME) Medicare administrative contractor (MAC) in either of the above situations.
However, payment for ankle-foot orthoses or knee-ankle foot orthoses delivered to a beneficiary in a hospital or a Part A-covered SNF stay is eligible for coverage by the DME MAC if all of the following criteria apply:
- The orthosis is medically necessary for a beneficiary after discharge from a hospital or an SNF stay covered by Part A.
- The orthosis is provided to the beneficiary within 2 days prior to discharge to the person’s home.
- The orthosis is not needed for inpatient treatment or rehabilitation but is left in the room for the beneficiary to take home.
Medicare resources
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Medicare Part B covers therapeutic shoes and inserts for people with diabetes and severe diabetes-related foot disease, as well as medically necessary ankle-foot orthoses and knee-ankle foot orthoses.
After a person meets the Part B deductible, which is $240 in 2024, they pay 20% of the Medicare-approved amount.
However, Medicare will only cover an individual’s therapeutic shoes if their doctors and suppliers are enrolled in Medicare. If their doctors or suppliers are not enrolled, Medicare will not pay the claims they submit.
People should ask their suppliers whether they participate in Medicare before they get therapeutic shoes.
If suppliers do participate in Medicare, they must accept assignment. This means they can only charge someone the coinsurance and Part B deductible for the Medicare-approved amount.
If suppliers are not participating and do not accept assignment, there is no limit to the amount they can charge someone.
Orthoses
Medicare Part B covers braces, including ankle-foot orthoses and knee-ankle-foot orthoses, when medically necessary and if a Medicare-enrolled doctor or other healthcare professional orders them.
After a person meets the Part B deductible, they pay 20% of the Medicare-approved amount.
In certain cases, these devices are covered in the payment for an inpatient hospital or an SNF stay covered by Part A.
People must meet the Part A deductible, which is $1,632 in 2024, for each inpatient hospital benefit period, before Original Medicare starts to pay. Additional costs a person may need to pay vary depending on how long their hospital inpatient or SNF stay is.
If a person’s hospital inpatient stay lasts 1 to 60 days, they will only need to pay the Part A deductible. However, if their stay lasts longer than 60 days, the following costs apply:
- Days 61 to 90: A person pays $408 each day.
- Days 91 to 150: A person pays $816 each day while using their 60 lifetime reserve days.
- After day 150: A person pays all costs.
If a person’s SNF stay lasts 1 to 20 days, they will only need to pay the Part A deductible. However, if their stay lasts 21 to 100 days, they will need to pay $204 each day. They pay all costs for days 101 and beyond.
The doctor who treats an individual’s diabetes must certify the person’s need for therapeutic shoes or inserts.
A podiatrist or other qualified doctor must prescribe these shoes or inserts, and a person must get them from one of the following:
- a podiatrist
- a pedorthist
- an orthotist
- a prosthetist
- another qualified individual
People may want to talk with their doctor or supplier about how much their therapeutic shoes and inserts or orthoses will cost.
The exact amount they owe will depend on a range of factors, such as:
- where they get their item or service
- whether their doctor accepts assignment
- how much their doctor charges
- other insurance they may have
- the type of facility
Asking questions can also help a person understand why their doctor is recommending certain services and whether or how much Medicare will pay for them.
In some cases, healthcare professionals may recommend a person gets services more often than Medicare covers, or they may recommend services that Medicare does not cover.
Finally, individuals may want to ask about how to use their prescribed items correctly, as well as how to maintain them.
Medicare Part B covers therapeutic shoes and inserts, or orthotics, for people with diabetes and severe diabetes-related foot disease, as well as medically necessary ankle-foot orthoses and knee-ankle foot orthoses.
In certain cases, ankle-foot orthoses and knee-ankle foot orthoses may be covered under Medicare Part A.