Orthotics are devices that correct foot deformities, relieve pain, maintain proper body weight distribution and alignment, and support other body parts. While many orthotics can be bought over the counter (OTC), doctors typically prescribe them to support treating orthopedic issues like osteoarthritis, back pain, foot pain, spinal injury, and plantar fasciitis.
While insurance can offset some or all of the costs of getting an orthotic device, coverage varies, depending on the insurance company, medical necessity, and availability of supporting documents like a doctor's prescription. Purchasing orthotics, especially functional and custom-made devices, can be expensive; hence, you should confirm with your insurer if they cover them.
Will My Insurance Cover The Cost of Getting an Orthotic Device?
Yes, most insurance companies typically cover the cost of getting an orthotic device; however, coverage depends on factors like the insurer, the device's price, the baseline of the patient (age, lifestyle, gender), and medical necessities, amongst other factors. Let’s take a look:
Employer-Sponsored Insurance
If your health insurance is sponsored through your job, check if the plan covers Durable Medical Equipment (DME). DMEs are medical equipment that lasts long, like wheelchairs, crutches, or orthotics. While your plan might not explicitly say 'orthotics,' they are typically covered under DME.
Marketplace vs. Off-Marketplace Policies and Orthotics
When shopping for orthotics, you may choose between marketplace healthcare plans and off-marketplace policies. Marketplace policies are sold on government-run exchanges like healthcare.gov, while off-marketplace policies are sold directly by insurance companies.
Off-market policies offer several benefits, including low and discounted pricing. However, they may have limited coverage for orthotics, leading to more out-of-pocket payments. Other times, specific orthotics may not be covered. You must review your healthcare plan to know what it covers and how much out-of-pocket payments you would incur.
The Type/Category of Orthotics
Over-the-counter (OTC) Orthotics: OTC orthotics are usually the least expensive and can be purchased online or in pharmacies. OTC orthotics include heel cups, insoles, and cushioned insoles – and are used for comfort.
Accommodative Orthotics: Accommodative orthotics are used by patients with conditions like diabetes to cushion pressure on the feet. While their design and architecture make them more expensive than OTC orthotics, they are not sufficient to correct specific foot deformities. An insurance company can deem accommodative orthotics as cosmetic or purely for comfort and refuse to cover them.
Specialty orthotics: Specialty orthotics are prescribed and used by specialists to either correct or prevent further deformity in cases like flat feet and plantar fasciitis. They can be pricey and are usually a part of a much wider array of treatment options for foot deformities. Confirm with your insurer if they cover the devices, alongside other services like consultation and surgery – if needed.
Functional Orthotics: Functional orthotics help improve body alignment, weight distribution, and posturing by controlling abnormal foot motion. They are more rigid than OTC products and are used to correct or prevent further deformation from conditions like splits, overpronation, flat feet, and injuries from sports. Functional orthotics may require in-person fitting and follow-ups and may come as a complementary treatment alongside physical therapy and surgery. High-end functional orthotics – the ones used to treat sport-related injuries – can cost considerably more. If you have an active lifestyle that includes sports, your insurance company may require a higher premium, given your sports injury exposure.
Custom Orthotics: A custom orthotic can only be prescribed by healthcare professionals to treat individual foot deformities. To get custom orthotics, a doctor must assess your feet and design the orthotic to match your specific condition. Because of the job's level of expertise and specialty, custom orthotics are typically the most expensive. Many insurance companies will require supporting documentation and may only grant coverage if pre-approved professionals and institutions make the prescription.
Things to Look Out for When Studying Your Employee-Sponsored Plan
- Deductibles: The amount you pay out-of-pocket before your insurance company can cover costs.
- Copays or Coinsurance: The amount you will pay for medical services like prescriptions or consultations. Your insurance company may require that you pay a flat fee (copay) or a percentage of the cost (coinsurance).
- Open Enrollment Period: A period where you can alter your insurance plan. If it's near, you may seek changes to include orthotics. You can confirm if the new plan covers orthotics if you are changing jobs.
General Requirement for Coverage
- Medical Necessity: Insurance companies may require documentation by specialists to affirm the occurrences of medical conditions like plantar fasciitis and structural deformity of the feet before covering the costs of obtaining orthotics.
- Prescription: A prescription tells the insurer the use of the orthotics – for pain alleviation, comfort, or prevention of more damage to the body.
- Pre-authorization: Some insurance companies will request a review of your prescription and supporting documentation, especially when you want custom-made orthotics that typically cost more.
How to Ensure Insurance Reimbursement for Orthotics
To ensure insurance reimbursement for custom orthotics,
- Research Insurance Plans: Even if you are already on one insurance plan, check the SBC document to confirm if they cover custom orthotics. An SBC (Summary of Benefits & Coverage) document tells you everything you should know about your plan, including cost-sharing, coverage limits (including the number of orthotics they will cover in a year or the maximum number of orthotics they will cover throughout your plan), and exclusions.
- Confirm the Terms of Your Orthotics Coverage: SBC documents can be found on your insurance company's website. If you have questions or notice that the SBC uses vague language, call them to confirm all scenarios where you might need an orthotic device. Don't make assumptions.
- Choose a Plan that Suits Your Needs: When choosing an insurance plan, consider your orthotics need, whether custom, specialty, or OTC. Choose a plan with reasonable coverage, regardless of the orthotic type. Other factors to consider are claims process and out-of-pocket costs.
- Research the Insurance Company: Don’t just speak to the insurance company over the phone. Look them up on review websites like Trustpilot and Better Business Bureau.
Note: Insurance companies will assess your health history to ensure that your baseline (health history, age, sex, lifestyle) matches their criteria. They may increase your premium if they feel your baseline deviates considerably from their ideal client.
Medicare Vs. Medicaid Orthotics Coverage
Medicare Part B, a key part of the Federal Insurance Health Program that covers outpatient and medically necessary services, covers orthotics. However, to be eligible, the device must be prescribed by a medical doctor. Beyond orthotic devices, Medicare Part B also covers orthopedic shoes as long as they are medically necessary.
Like Medicare, Medicaid covers orthotics; however, because federal and state governments jointly fund it, individual states may have different policies like the orthotics covered, eligibility requirements, copays, and out-of-pocket costs.
