How To Get Orthotics Covered by Insurance

Introduction

Many people would like to take advantage of custom orthotics to help improve their foot health and its impact on their overall health. Custom orthotics costs (those not bought off the shelf) can range from $300 to $800 for custom-cast molded fittings. Fortunately, most insurance plans and health care services will cover prescription-required custom orthotics.

Typically, getting the cost of custom orthotics covered by your insurance provider isn’t complicated, so long as you follow a few important guidelines. Here are a few easy steps to ensure the cost of your orthotics is fully covered or reimbursed. 

Step 1: Choose your policy carefully

The insurance marketplace offers an array of plans suited to a variety of needs. If you are self-employed, you will have a greater selection of plans. If you are employed, your company will have a choice of pre-negotiated coverages available. These plans range from very low to very high deductibles and offer a broad spectrum of coverage.

Choosing one that specifically covers custom orthotics is a relatively straightforward process. 

Companies such as Aetna, Blue Cross Blue Shield, United Healthcare, and many others specifically outline custom orthotics coverage in their various health plans. Coverage for orthotics falls under the Durable Medical Equipment (DME) section of all plans. Employer healthcare plans commonly include DME under their umbrella of coverage. If your plan does not include coverage for DME, you will be paying out-of-pocket for your devices.

Aetna

Aetna provides customers access to policy bulletins, in which coverage regarding orthotics is clearly outlined. They consider orthosis (orthotics) medically necessary and covered when specific criteria are met. Criteria include:

• Care is prescribed by a physician, nurse practitioner, podiatrist, or other health care provider.
• The orthotics will significantly improve health or restore mobility.
• The orthotics are provided to the patient within six months of being prescribed.
• The certified orthotic must be in good standing with at least one predesignated medical board.

Blue Cross Blue Shield

BCBS has similar policy language regarding coverage. They indicate that each policy offers varying coverage but clearly outlines what is coverable.

Custom orthotics are covered under Blue Cross Blue Shield if:

• The custom orthotics are prescribed by a qualifying physician.
• The orthotics are medically necessary and designed to support or aid in treating an illness or injury.

These injuries include:

• Plantar Fasciitis
• Pes Planus (Flat Feet)
• Pes Cavus (High-Arched Feet)

Coverage with Blue Cross Blue Shield may also apply in the absence of a primary diagnosis so long as certain conditions are met. These include:

• The orthotics are provided concurrently with Chiropractic Manipulative Therapy.
• There is documented objective evidence supporting the need for custom foot orthotics in the treatment plan.
• The prescription is consistent with the goals of the treatment plan.

United Healthcare

United Healthcare, another primary insurance provider, offers coverage of custom orthotics with relatively similar restrictions. These restrictions include:

• The equipment is ordered by or prescribed by a physician to treat an injury or sickness.
• The orthotics are not otherwise excluded in the member benefit plan document (Many lower-tier plans exclude a litany of devices in their coverage, including orthotics).
• The orthotics are not disposable (one-time use).
• Not of use to a person in the absence of a disability or disease.

There are other stipulations in the fine print of each policy at United Healthcare. It is best to speak directly with UH to clarify coverage terms and restrictions.

Step 2: Make that call

For clarification on all plans and coverage, Healthcare.gov offers a toll-free number available 24 hours a day, seven days a week (excluding holidays): 1-800-318-2596. By calling this number, you will be patched through to a healthcare specialist who will ensure that your chosen policy has the right coverage. Ensure you communicate your desire to have custom orthotics fall under their coverage umbrella.

If calling a government hotline doesn’t appeal to you, calling the insurance companies directly is a great option. Each company offers a toll-free number, and agents on the other end are eager to help. State your desired coverage, budget, and deductible, and they will provide you with options. Ask all questions related to the fine print. You want to ensure that the coverage applies to your specific situation. If you are calling regarding employer-sponsored group healthcare plans, the healthcare specialist can review which fits your budget and expectations.

Step 3: Take the necessary steps to ensure coverage

Now that you’ve chosen a suitable plan that offers complete coverage of your orthotics (DME), you will need to follow protocol to ensure that your coverage applies. Many providers have strict protocols regarding how orthotics will be covered. The first step usually entails obtaining a diagnosis from a podiatrist or foot specialist. You will want to use an in-network doctor, as it generally expedites and streamlines the process.

After you are examined and determined that custom orthotics are appropriate, your podiatrist will write a prescription. Many insurance providers require additional information, such as the raw materials used in the construction of the orthotics, the casting process, warranty information, etc. While the manufacturer often provides this information, sometimes it is up to the customer to obtain and submit it, especially in cases of reimbursement.

Step 4: Go the extra mile

Additional requirements may be necessary. Some insurance providers will have you submit things such as a biomechanical gait analysis report, a list of appointments with your podiatrist, a receipt showing proof of payment, and a transaction for the orthotics (in cases of reimbursement). It is up to you to follow protocol. Failure to do so can result in the claim being rejected. It is always wise to call your provider and double-check that all required items are submitted and accounted for and that the claim can proceed.

Step 5: Follow up with your doctor

Many plans require regular follow-ups for continued coverage. Talk to your doctor about an appropriate follow-up plan. Custom orthotics have a shelf life, and when they wear out, you want to be sure you are in good standing to receive another pair. Custom orthotics last between 1-5 years. Factors such as activity level, body weight, and material used in manufacturing all play a role in how long they last. Most policies account for this and cover replacements at various intervals.

Other Ways to Cover the Cost of Orthotics

If you don’t have a traditional insurance plan, you may have other ways to cover the cost of custom orthotics.

Use your FSA or HSA

If you have a Flexible Spending Account or Health Savings Account, there’s a good chance you’ll be able to use your funds to purchase custom orthotics. Check with your FSA or HSA provider.

Medicare and Medicaid

If you’re eligible for Medicare or Medicaid, many medical conditions provide the option for custom orthotics. Check with the plan representative first to see which conditions may qualify. Your orthotics may be covered.

Check with your employer

If your job requires you to be on your feet for most of the day or requires regular strenuous activity, your employer might be willing to help you cover the cost of your custom orthotics. Remember, healthy employees are productive employees. It may be a benefit you’re unaware of or an expense you can claim on your taxes.

The bottom line is that custom orthotics are generally covered for those who need them. If you have flat feet, high arches, plantar fasciitis, are diabetic, or suffer from other ailments that custom orthotics can improve, many insurance policies will cover the cost. It all comes down to investigating the policies, talking to your doctor, and determining the right coverage for your needs.

If you already have a policy that does not cover the cost of orthotics, you may have to wait until the next enrollment period to get covered. Talk to your healthcare provider to determine how or if you are covered.  

Quick Facts About Custom Orthotics:

- Custom Orthotics reduce the risk of injury by 28%

- Custom Orthotics reduces the risk of stress fractures by 41%

(source:  https://www.reuters.com/article/us-health-athletes-orthotics-idINKBN1442B8/)

- Many professional athletes and Olympians use custom orthotics (LeBron James included)

- The first orthotic was developed in 1905 by Royal Whitman. It was called the Whitman Brace

- The CDC estimates that nearly 2 million Americans use some form of orthotics.