Medicare Coverage for Therapeutic Shoes, Inserts, AFOs, and KAFOs

15 Oct 2019 Medical Coverage, Orthopedics, Tips

Health insurance is a complicated business, and Medicare is no exception. If you’re 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, you’ll pay 20% of the Medicare-approved amount with the Part B deductible applied.

Don’t 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.

Documentation from the ordering physician, such as chart notes and medical records, is required for coverage. Other required details include the history of the injury, illness, or condition, description of limitations of a typical day, status of the current orthosis, and reason for replacement.

Don’t forget any of the paperwork required for your AFO or KAFO. Review this list of documentation required by Medicare.

Know Your Durable Medical Equipment (DME) Coverage Terms

1 Oct 2019 Lifestyle, Medical Coverage, Tips

Jeez, health insurance coverage is a complicated business. However, knowing a few key terms can go a long way to making it more understandable. Take a look at the following terms. With these in your arsenal, you’ll confidently navigate your way through insurance documents.

Premium

The amount the policy-holder or their sponsor (such as an employer) pays for a health plan.

Deductible

The amount the insured (that’s you!) must pay out-of-pocket before the health insurer pays its share. For example, policy-holders might have to pay a $500 deductible per year before any of their health care is covered by the health insurer. It may take several doctor’s visits or prescription refills before the insured person reaches the deductible and the insurance company starts to pay for care. Some plans may have separate deductibles for specific services.

Co-Payment

The amount the insured person (you, again!) must pay out-of-pocket before the health insurer pays for DME. For example, an insured person might pay a 20% co-payment for an orthotic device.

Exclusions

Exclusions are services that are NOT covered. Insured are generally expected to pay the full cost of non-covered services out of their own pockets. Please note that foot orthotics are often excluded unless the patient has a diabetes diagnosis.

Coverage Limits

Some health insurance policies only pay for health care up to a certain dollar amount. The insured person may be expected to pay any charges in excess of the health plan’s maximum payment for a specific service. In addition, some insurance company plans have annual or lifetime coverage maximums. In these cases, the health plan will stop payment when the benefit maximum is reached and the policy-holder must pay all remaining costs.

Out-of-Pocket Maximums

The insured person’s payment obligation ends when they reach the out-of-pocket maximum, after which the health insurance pays all further covered costs. Out-of-pocket maximums can be limited to a specific benefit category or can apply to all coverage provided during a specific benefit year.

In-Network Provider

In-network refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider.

Prior Authorization

A certification or authorization an insurer provides prior to medical service stating it will cover a percentage of the cost. This is often required for DME.

Explanation of Benefits

A document by an insurance company to a patient and the provider of service explaining what part of the medical service was covered.

Referral

A written order from your primary care doctor or specialist that is always required by our office. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

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