Medicare Advantage Coverage For Various Types Of Orthotics
Did you know you can get your Medicare Part B benefits through a type of Medicare plan thats available through private, Medicare-approved insurance companies? The program is called Medicare Advantage, or Medicare Part C, and its another way to get your Medicare coverage. Many Medicare Advantage plans even include prescription drug coverage thats something for which Original Medicare, Part A and Part B, offers only limited coverage, typically not extending to the prescription medications you take at home. There may be a choice of Medicare Advantage plans available in your area. You need to continue paying your Part B premium when you have a Medicare Advantage plan, along with any premium the plan may charge.
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This website and its contents are for informational purposes only. Nothing on this website should ever be used as a substitute for professional medical advice. You should always consult with your medical provider regarding diagnosis or treatment for a health condition, including decisions about the correct medication for your condition, as well as prior to undertaking any specific exercise or dietary routine.
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Does Medicaid Cover Orthotics Without A Copay
State Medicaid programs are allowed to charge nominal copays for some services, including orthotics. In most states, the copay is a flat fee, but some states require enrollees to pay for a certain percentage of the cost. For example, South Dakota requires enrollees to pay 5% of the Medicaid-approved amount. Some states set their copays based on each enrolleeâs financial situation. In Montana, enrollees who are at or below 100% of the Federal Poverty Level pay a $4 copay, while enrollees above the Federal Poverty Level pay 10% of the cost. Many states require no copays for orthotics, including Arizona, California, Connecticut, Hawaii, Louisiana, Massachusetts and Vermont.
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Patient Responsibility For Payment
Medicare will pay for 80% of the Medicare-approved amount either directly to the patient or by reimbursement after the Part B deductible is met. The patient is responsible for a minimum of 20% of the total payment amount and possibly more if the dispenser does not accept Medicare assignment and if the dispenser’s usual fee is higher than the payment amount.
Medicare pays only for therapeutic footwear from Medicare-approved suppliers, reimbursing 80% of the cost either to the patient or after the Part B deductible is met. The patient is responsible for the other 20% — or more if the supplier does not “accept assignment” from Medicare.
Medicare.gov: Medicareâs Coverage of Diabetes Supplies & Services.
The National Institute of Diabetes and Digestive and Kidney Diseases of The National Institutes of Health. Publication: Feet Can Last a Lifetime: Medicare Coverage of Therapeutic Footwear for People with Diabetes. 1998.
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Medicare To Allow Nurse Practitioners And Physician Assistants To Certify The Medical Need For Diabetic Shoes In Limited Circumstances
AOPA, in collaboration with other healthcare organizations, has actively supported the inclusion of nurse practitioners and physician assistants to serve as certifying practitioners under the Medicare diabetic shoe benefit. The Social Security Act states that the certifying physician must be the MD or DO that is managing the patients systemic diabetic condition. This has led to significant access issues as the delivery of healthcare has evolved and non-physician practitioners have become more prevalent as primary care providers.
The Durable Medical Equipment Medicare Administrative Contractors recently announced two separate pathways that expand the ability of NPs and PAs to certify the medical need for diabetic shoes provided to Medicare beneficiaries.
The first pathway only applies to NPs and is being coordinated by the Center for Medicare and Medicaid Innovation through the Primary Care First demonstration project. The PCF demonstration project will be implemented on January 1, 2021 and will run through December 31, 2025. NPs that are participating in the PCF demonstration project in one of the 26 states/regions that it will be implemented in may serve as the certifying practitioner for diabetic shoes covered by Medicare. The PCF model does not require the NP to operate under the direct supervision of a physician, but it does not apply to physician assistants. The announcement of the expansion of the role of NPs under the PCF demonstration project may be viewed HERE.
Medicare Coverage For Therapeutic Shoes Inserts Afos And Kafos
Health insurance is a complicated business, and Medicare is no exception. If youre a Medicare recipient and in need of therapeutic shoes, inserts, an AFO, or a KAFO, follow the guidelines below to ensure you get the coverage you need.
Diabetic Shoes and Inserts
Medicare recipients are entitled to one pair of custom-molded shoes with inserts or one pair of extra-depth shoes each calendar year. Medicare also covers two additional pairs of inserts each calendar year for custom-molded shoes and three pairs of inserts each calendar year for extra-depth shoes.
However, to receive this coverage, a podiatrist or qualified doctor must prescribe these items. Patients must also have been seen by the doctor treating their diabetes no more than 90 days prior to receiving the shoes.
If you meet the above requirements and your provider accepts Medicare, youll pay 20% of the Medicare-approved amount with the Part B deductible applied.
Dont let a missing document stop you from getting the diabetic shoes or inserts you need. Review this Medicare document checklist to make your order easy and painless.
AFOs and KAFOs
Medicare will also cover AFO and KAFO prescriptions, although additional documentation and notes are necessary to receive full benefits.
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Medicare Covered Diabetic Shoes Or Online Retailers
Although the Medicare program does cover some of the cost of diabetic shoes , the patient is still required to pay for their shoes out of pocket. The disadvantage of purchasing Medicare diabetic shoes is that doctors and physicians often charge exorbitant prices for the shoes and inserts that are much higher than if the items were bought out of pocket from a retailer.
Diabetic shoes typically retail anywhere from $100-$160 for a good quality pair, however the prescribing physician will charge Medicare up to four times that amount with the bill coming out to upwards of $500. Medicare will cover 80% of the charge but you will still be responsible for covering the other 20% which is $100.
Online retailers have seen the growing need for diabetic footwear and have began to expand their product selection to better suit diabetic patients. Many online retailers offer excellent diabetic shoes that are the same ones supplied by the prescribing physician at the retail price. If additional shoes are needed, online retailers are another great option to think about.
Need More Information On Medicare Reimbursement
We can provide a brochure to take to a Primary Care Physician to see if youre eligible and get the paperwork started. This pamphlet explains the process for both the patient and doctor with and includes simple instructions and forms the doctor needs to complete. It also has some important facts about diabetes foot health.
To receive this free brochure in the mail, along with one of our catalogs and a list of providers in your area, email your request with your name and address to
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What Diabetic Shoes Will Medicare Cover
Medicare allows one pair of extra-depth shoes and one pair of custom-molded shoes per calendar year. Also, Medicare covers up to five pairs of inserts each calendar year.
If the doctor or supplier submitting the claims for your diabetic shoes and/or inserts doesnt accept Medicare, Medicare wont pay the claims. You should always contact your supplier to make sure they participate in Medicare beforehand. If the supplier participates in Medicare, they accept Medicare assignment. Remember, if the supplier doesnt accept Medicare, they control how much they can charge you.
How To Qualify For Medicare Diabetic Shoes
In order to qualify for Medicare covered diabetic shoes and diabetic insoles, a podiatrist must prescribe the items and the prescription must be filled by any of the specific health professionals as mentioned above. The prescribing doctor must complete a certificate of medical necessity for diabetic shoes and it must be documented in the patient’s medical records.
In order to qualify for the coverage of diabetic shoes, patients must be covered under Medicare Part B and meet all three of the following conditions:
1) Patient has diabetes
2) Patient has at least one of the following conditions:
- Partial or complete foot amputation
- Foot ulcers
- Nerve damage in feet w/ signs of calluses on either foot
- Foot deformities such as hammertoes or bunions
- Poor circulation in the feet
3) Patient’s doctor certifies in writing stating that:
- The aforementioned requirements are met for diabetic shoes
- Patient’s certifying physcician is treating them for diabetes under a comprehensive plan of care
- Specific reasons why patient needs diabetic shoes and/or inserts
Medicare does not offer coverage for diabetic shoes if all three of these requirements are not met.
Clinicians Are You Ordering Diabetic Shoes For Your Patients
This article has been revised as of March 2021.
The following section outlines roles of various practitioners that are involved in the decision-making and provision process for Diabetic Shoes:
- Certifying Physician: The practitioner actively treating and managing the patient’s systemic diabetic condition. This practitioner must be an M.D. or D.O. as outlined in the Social Security Act §1861 .
- Prescribing Practitioner: The Certifying Physician, a different MD or DO, physician’s assistant , nurse practitioner , clinical nurse specialist , or podiatrist . One of these practitioners may conduct the foot exam and write the standard written orders required for Medicare’s coverage of Therapeutic Shoes for Persons with Diabetes if the Certifying Physician does not complete the foot exam.
- Supplier: The person or entity that provides the shoes and/or inserts to the Medicare beneficiary and bills the Medicare program. A supplier may be a podiatrist, pedorthist, orthotist, prosthetist or other qualified individual. The Prescribing Practitioner may be the supplier.
Recent Centers for Medicare and Medicaid Services Guidance and a new Center for Medicare and Medicaid Innovation recently expanded who may perform the role of the Certifying Physician as described below:
NPs or PAs providing ancillary services as auxiliary personnel could meet the incident to requirements if all the following criteria are met:
Diabetic Shoes Things To Know
We offer a wide selection of diabetic shoes from Dr. Comfort, Apex and Orthofeet..
What are diabetic shoes?
Diabetic shoes, sometimes referred to as extra depth, or therapeutic shoes, are specially designed shoes intended to reduce the risk of pressure and or skin breakdown in those suffering from diabetes. These shoes have a wider and deeper toe box compared to traditional shoes . The primary goal of diabetic footwear is to prevent foot complications, which can include strain, ulcers, callouses, or even amputations for those poor circulation related to diabetes. These shoes are manufactured under strict guidelines and they must be equipped with a removable orthotic. The shoes and insoles work together as a preventative system to help provide joint stability, prevent joint deformity , and improve overall mobility.
Do I need a prescription?
The purchase of diabetic shoes does not require a prescription. However, insurance company guidelines require that diabetic shoes be prescribed by a physician and fitted by a qualified individual such as a Certified Orthotic Fitter. Here at Aston Pharmacy, we have a Certified Orthotic Fitter to meet all of your diabetic shoe needs.
Will insurance or Medicare cover diabetic shoes ?
Most insurance companies will cover part or all of the cost of diabetic shoes and insoles. Each insurance company has their own requirements for coverage. Here a few guidelines:
Medicare and Keystone 65 –
Blue Cross/Blue Shield and other Commercial insurances–
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Can Medigap Help Cover The Cost Of Diabetic Shoes
A Medigap policy may be just what you need to help cover your diabetic shoes. Medicare Supplement plans are a great asset in helping with extra costs. Because Medigap plans cover the balance of what Medicare does, Medicare Supplement policies can help cover the out-of-pocket expenses you may have when getting diabetic shoes.
Where Do I Get My Diabetic Shoes
- In order to receive diabetic shoes, the prescribed patient must be fitted for diabetic shoes by a podiatrist or any other qualified individual.
- The certifying physician is not allowed to provide the patient with the footwear, unless they practice in a defined rural area or there is a shortage of health professionals
- The prescribing physician may be the supplier.
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How Can A Podiatrist Help With Toenail Fungus
Your podiatrist will suggest temporary removal of the affected nail so that anti-fungal drugs can be applied directly to the nail bed where the infection lies under the nail.
- If your toenails are extremely painful or have severe fungal infections, permanent nail removal may be done by your podiatrist.
- Do your toenails give a foul smell or an unsightly appearance? Then it would be best if you visited the right doctor for complete treatment that is, a podiatrist. Your podiatrist will create a treatment plan that fits your needs and your lifestyle best.
- Isnt it frustrating and often difficult to tackle a toenail fungus on your own? Perhaps you have tried many treatment options before. Your podiatrist will offer modern professional treatment methods to clear up your toenail fungus, which is much more effective than home remedies and over-the-counter medications.
- A podiatrist is a doctor qualified to deal with your foot and ankle problems, including toenail fungus, and they are dedicated to making you feel comfortable throughout the treatment process.
- Your podiatrist may even use modern therapies like LASER to eliminate the infection.
How Much Do Diabetic Shoes Cost
Diabetic shoes can be costly because theyre specialty shoes and need to be custom-fitted for your feet. On average, diabetic shoes can range in cost from $50-$200 per pair.
Your out-of-pocket costs may depend on several factors:
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What Is The Therapeutic Shoe Bill
Congress passed the TSB or diabetic shoe benefit a while back. Ever since the bill was passed, Part B provides reimbursement for therapeutic shoes, inserts, and modifications for beneficiaries with diabetes who meet specific eligibility requirements.
You may be eligible if you have diabetes, documentation from a qualified physician, and at least one of the following:
- Amputation of all or part of either foot
- Foot deformity
- Diabetic neuropathy with evidence of callus formation
If youre unsure about your eligibility, you can contact a Medicare representative.
Custom Orthotics Vs Over
If youâve ever seen a rack of orthotics at your local pharmacy, you may think that their only purpose is to give your feet a little extra support. Thatâs not the case with custom orthotics. Unlike inexpensive orthotics that can be bent in half without much effort, custom devices are somewhat rigid. Theyâre designed to correct deformities, keep the feet and ankles in proper alignment, improve joint function and protect the feet and ankles from stress.
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How Do I Qualify For The Coverage Of Diabetic Shoes
You must be covered under Medicare Part B and all three of the following conditions are met:
1. You have diabetes and
2. You have one or more of the following conditions:
- Partial or complete foot amputation
- Past foot ulcers
- Nerve damage in your feet with signs of calluses on either foot
- Deformity of either foot
- Poor circulation in either foot.
3. Your doctor has certified your need in writing, and it states that:
- You meet the criteria for the shoes
- The doctor is treating you under a comprehensive plan of care for diabetes
- The exact reasons you need the therapeutic shoes and/or inserts
- Only an M.D. or D.O. can sign the certification statement a podiatrist may write the prescription for the shoes, but the M.D. or D.O. who is treating your diabetic condition must certify it. While a podiatrist can prescribe diabetic shoes, they cannot sign the physicians certification statement.
- You will need a new order for the replacement of any shoe
- A copy of the certification statement and prescription must be kept on file by your supplier
- A new certification statement will be required for shoes, inserts or modifications each year they are purchased
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