Health Insurance and Orthotics Coverage
Millions of people rely on orthotics to lead active, pain-free lives. Although some health plans will help you pay for these braces, supports, and other devices, many will not. Here's all you need to know about how, when, and why insurance does and doesn’t cover orthotics.
Raise your hand if the first thought that ran through your mind when you saw this article’s headline was something along the lines of: Of course health insurance covers orthotics. Why wouldn’t it?
That attitude is understandable. Most people buy and use these braces, inserts, supports, and devices for medical reasons. Also, many health plans pay for prosthetics.
Prosthetics and orthotics aren’t the same things, of course. But they’re similar enough that it’s fair to think plans that cover one would cover the other as well.
In reality, some health insurance policies do cover orthotics (or orthoses, as some call them), but many do not.
Which do and which don’t? And why do some provide this coverage while others don’t? You’ll find answers to both questions – and others – here.
What is Orthotics?
Before we get to which health insurance options cover orthotics, let’s clarify what they are and what they aren’t.
That’s because many people seem to think orthotic is a fancy name for shoe insert.
It’s not. What’s the actual definition of the word? According to BlueCross BlueShield, an orthotic or orthosis is a “rigid or semi-rigid appliance or device” that is used to:
- Support, align, prevent, or correct deformities
- Protect a body function
- Improve the function of movable body parts
- Assist a dysfunctional joint
Orthotics also may “redirect, restrict, or prevent motion of an impaired body part.”
In other words, a shoe insert is just one example of an orthotic. Here are a few other examples:
- Foot pads, like the doughnut-shaped ones that cushion calluses or corns
- Orthotic, orthopedic, or therapeutic shoes
- Leg, arm, back, shoulder, or neck braces
- Splints and splinting systems that support those same body parts in various ways
Some people even think of artificial limbs, eyes, and organs as orthotics, though most consider them prosthetics.
For the purposes of this write-up, only the items above – foot pads, shoe inserts, shoes, and braces – “count” as orthotics.
How Does Health Insurance Cover Orthotics in General?
The quick answer to this question is a bit frustrating. In short, it depends on your plan.
At least some health plans won’t help pay for things like foot pads or shoe inserts. Still, some plans will help you – especially if a doctor prescribes them to treat a medical issue.
That’s especially true if your healthcare provider prescribes orthotic shoes or arm, back, neck, or leg braces.
Some plan types cover those products better than others, though, as you’ll learn in this next section.
How Each Type of Health Insurance Covers Orthotics
Whether or not you can rely on health insurance to pay for the orthotics you need depends a lot on the kind or type of plan you have.
Employer-sponsored or job-based policies and orthotics
It’s hard to make a definitive statement about how health coverage you get from an employer will treat orthotics.
The main reason is there are a ton of different job-based health plans out there these days.
That said, the little information that’s available on the subject suggests most of them provide at least some orthotics coverage.
For example, a recent Society for Human Resource Management survey found that 75 percent of large private employer plans cover “customized bracing.” And 70 percent of smaller private employer plans do the same. Large employers had 5,000 or more employees. Smaller ones had between 100 and 499 employees.
Customized bracing is just one kind of orthosis, though. Do these same plans also cover other kinds of orthotics? It’s impossible to say based on this survey’s results. It’s likely they do, at least to an extent, but it’s also possible they don’t.
Are you eyeing an employer policy? Whether you just switched jobs or your current job’s open enrollment period is about to begin, do your homework. Keep an eye out for whether or not the plan covers durable goods or durable medical equipment.
That’s typically the portion of a health plan that pays for orthotics. Don’t be surprised if it doesn’t specifically mention orthotics or orthoses.
Also, don’t be surprised if you’re charged a copayment or coinsurance for any orthotics your doctor recommends or prescribes. That’s a common part of many health insurance plans.
Marketplace or off-marketplace policies and orthotics
If you get coverage from the Affordable Care Act marketplace, it may or may not help you pay for orthotics.
Why the lack of consistency? The ACA requires plans to cover 10 categories of essential health benefits. One of those categories is “rehabilitative and habilitative services and devices.”
All healthcare.gov says is that rehabilitative and habilitative services and devices “help people with injuries, disabilities, or chronic conditions gain or recover mental and physical skills.”
The good news here is that many orthotics fit that definition. Braces, splints, and supports certainly do.
The bad news, though, is that the state you call home may not agree. If its benchmark plan doesn’t include orthotic devices, you may struggle to find marketplace policies in your area that cover them.
As is the case with employer health plans, though, you’re more likely to find at least one marketplace plan that pays for orthotics than you are to not find any at all.
While shopping for one of these policies, look for details on coverage of durable goods or durable medical equipment. And if that doesn’t make things clear, don’t be shy about picking up the phone or contacting the insurance company selling the policy.
For more information on marketplace plans, by the way, check out this article of ours: “Which Type of Obamacare Plan is Right for You?”
Medicare and orthotics
You’re in luck if you’re on Original Medicare (Medicare Part A and Part B) and you need orthotics.
That’s because Part B covers the most common types of these devices, such as.
- Orthopedic shoes (but only when they're a necessary part of a leg brace)
- Arm, leg, neck, and back braces
It also covers orthotics in general, according to medicare.gov, though that site doesn’t specify which supplies it considers to be orthoses.
Regardless, Medicare Part B only covers orthotics that are medically necessary. That means they have to “diagnose or treat an injury, illness, condition, disease, or its symptoms.” And they must “meet accepted standards of medicine.”
Part B also only covers orthotics if your doctors and suppliers are enrolled in Medicare. In the case of suppliers, they must “participate” and accept assignment, too. Why? Because suppliers that don’t accept assignment can charge what they want for supplies and services. Those that do accept assignment only can charge the Medicare-approved amount for them.
Speaking of which, if you buy your orthotics from “participating” suppliers, you’ll pay just 20 percent of the Medicare-approved amount for them. Though the Part B deductible applies, too.
To learn more about how this form of health insurance works in this and other situations, read through our comprehensive Medicare guide.
Medicaid and orthotics
Medicaid provides health insurance to millions of Americans who have a financial need.
It covers many important health treatments, services, and supplies. Among them: doctor visits, hospital stays, and nursing facility care.
Although some Medicaid programs will pay for or help you pay for orthotics, they don’t have to do so. Federal law requires them to cover several mandatory benefits, but many others are optional.
Prosthetics and podiatry services are two examples of benefits states can opt to offer or not via their Medicaid programs.
Medicaid.gov doesn’t list orthotics along with them, but that doesn’t mean you’re on your own if you need them and you’re on Medicaid. Many state programs pay for these devices if a physician prescribes or recommends them. Or at least that was the case back in 2012, according to this Kaiser Family Foundation report.
How can you find out if yours does or doesn’t cover orthotics? Simple: call or email your local agency and ask.
What is the Best Health Plan for People who Need Orthotics?
If you need orthotics and you don’t want to pay for it out of your own pocket, your best bets are:
- Employer-sponsored or job-based health coverage
- Original Medicare (Medicare Part B, in particular)
Medicare is an especially good option here as it covers a wide range of orthotic devices if a doctor prescribes them. (And as long as you buy them from participating suppliers that accept assignment.)
Granted, only certain Americans can enroll in Medicare. You need to be 65 or older, or you need to have a disability, ALS, or end-stage renal disease.
If you don’t fit into any of those categories, you’re out of luck as far as Medicare is concerned. In that case, the best kind of health insurance for people looking for orthotics coverage is the kind you can get from an employer.
Although there’s no guarantee your employer health plan will pay for the exact orthotic you need, it’s more likely than if you go for a marketplace plan.
What if marketplace or off-marketplace plans are your only option? Do your research. Shop around. Take your time to compare the policies you come across before you choose one over the others.
Although a few insurance companies are known for not covering orthotics, most do so to some extent. Aetna, BlueCross BlueShield, and UnitedHealthcare are good examples. All three limit their orthotics coverage in various ways but still pay for the devices in a number of situations.
Before you sign on the dotted line for any of them, see this article of ours: “Which Type of Health Insurance Plan is Right for You?” And this one, too: “Everything You Need to Know to Apply for Health Insurance.”
How You Can Tell if Your Health Insurance Plan Covers Orthotics
The quickest and easiest way to tell if your health insurance policy pays for any kind of orthotic is to look at its Summary of Benefits and Coverage, or SBC.
You might have a copy of this lying around your home. If that’s not the case, don’t worry. You can get one from the insurance company with a call, email, or even Google search.
Your plan’s SBC may not tell you everything you want to know in this area, though. It’ll mostly tell you the basics of what your plan covers as well as the deductibles, copayments, and other out-of-pocket costs associated with that coverage.
Still, it might mention durable goods or durable medical equipment. Even then, though, it might only tell you the copays or coinsurance percentages tied to such supplies.
To find out for sure if specific orthotic devices count as durable goods or durable medical equipment under your plan, contact the insurer.
Other Frequently Asked Questions
Q: Why do people use orthotics?
A: Here are the most common reasons people need and use orthoses:
- To restrict the movement of a body part, segment, or joint
- To assist the movement of a body part
- To correct the shape or function of a body part
- To otherwise control, guide, or immobilize a body part
- To help a fractured or broken bone heal (especially after the removal of a cast)
Some of the health or medical conditions that can cause someone to need an orthotic brace or device include:
- Cerebral palsy
- Spina bifida
- Spinal cord injury
That’s just the tip of the iceberg, though. Doctors can and do prescribe orthotics for many other conditions or reasons.
Q: Are orthotics and prosthetics different? Or how are orthotics and prosthetics different?
A: Yes, prosthetics and orthotics are different.
Human Technology, a prosthetics and orthotics company, says “while an orthotic device is used to enhance a person’s limb, a prosthetic device is used to replace a limb entirely.”
Most people who use orthotics, the site adds, “have difficulty using their arms or legs due to deficiencies or deformities. Or they rely on the devices to “provide comfort and healing to the limb by reducing shock or decreasing inflammation and swelling.”
People who use prosthetics, on the other hand, “typically need them as a result of injury or a birth defect, although certain conditions such as diabetes can increase a person’s likelihood of losing a limb and requiring a prosthetic device.”
Speaking of diabetes, people who develop that disease “often require the use of orthotics at some point in their life.” Many eventually require a prosthetic device, too. If they have a foot amputated, for instance.
Q: How much do orthotics cost?
A: If you have health insurance that covers orthotics, you might pay very little out of pocket for them. A small copay or a coinsurance charge of around 20 percent isn’t unusual.
If you don’t have a health plan that covers these devices, you’ll have to pay a bit more. How much more? Once again, it’s hard to say.
Most of the cost estimates online focus on off-the-shelf or custom shoe inserts. If that’s what you need, you could spend as little as $10 for something you buy at your local pharmacy, supermarket, or department store. Or you could spend $800 or more for a custom-fit device that’s molded to the shape of your foot.
Arm, leg, and back braces cover a similarly wide range of prices. You might pay $20 or less for a fairly simple ankle brace, for example. A top-of-the-line knee brace, though, could cost you over $500.
Q: How long do orthotic devices last?
A: Again, it depends. Some shoe inserts, especially the kind you buy off the shelf, may last just a few months. Custom-made ones might last several years.
The same is true of braces, splints, and other supports. Most should last for years, but how they’re used has a lot to do with that.
If you’re worried your orthosis is wearing out and needs to be replaced, talk with your doctor or physician.
Q: My health insurance won't pay for the orthotics I need. What can I do? What are my options?
A: If you’re on Medicare and it either won’t pay for the orthotic device you need, or it won’t pay for it fully, two options to consider are:
- Medicare Advantage plans
- Medicare Supplement insurance
Medicare Advantage plans provide all your Medicare Part A and Part B coverage, plus a bit more, in most cases.
What does that mean? Well, some cover vision, hearing, or dental care. Some cover prescription drugs. Some cover deductibles and copays.
You may be able to find a Medicare Advantage plan that does an even better job that Original Medicare of covering the orthotics you need. Or you might find one that covers the copays you’re charged when you go to buy those devices.
For more information on this type of coverage, check out our “Guide to Medicare Advantage Plans.”
Another option for people in this situation is Medicare Supplement insurance, which also is known as MedSup and Medigap.
You get these plans from private companies rather than through the federal government. They provide extra coverage and pay for things Original Medicare doesn’t.
Most people get MedSup plans to help them pay their Part A or B deductibles, coinsurance costs, or excess charges.
That’s not all they cover, though. And it’s not the only reason people purchase them. Learn more by reading our Medigap FAQ. Or read this article: “When Does it Make Sense to Get a Medicare Supplement Plan?”
What can you do if you get your health insurance from an employer, the Obamacare marketplace, or an insurer directly?
Most let you use their funds to pay for orthotic devices. Don’t assume that’s the case for any FSA or HSA you open, though. If you have an FSA, ask your employer if you can use it to buy the orthotics you need. If you have an HSA, check with the company that sold it to you.
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