Coverage for Orthotics

 

All health plans and insurers to are now required to offer (make something available for those who want it) coverage for orthotic and prosthetic devices

and services as follows:

  • Annual and lifetime maximums for orthotic and prosthetic devices and services cannot be lower than the maximums applicable to other plan benefits; and
  • Copayments, coinsurance, deductibles, and maximum out-of-pocket amounts cannot be higher than the most common amounts on the benefit plan.  AB 2012  Health and Safety Code §1367.18 Insurance Code §10123.7

What is an Orthotic?

 

A removable shoe insert, otherwise known as a foot orthoses, accomplishes many number of purposes, including daily wear comfort, foot and joint pain relief from arthritis, overuse, injuries, and other causes such as orthopedic correction, smell reduction and athletic performance. wikipedia.org/Shoe_insert

Foot orthoses comprise a custom made insert or footbed fitted into a shoe. Commonly referred to as “orthotics” these orthoses provide support for the foot by redistributing ground reaction forces as well as realigning foot joints while standing, walking or running. A great body of information exists within the orthotic literature describing the sciences that might be used to aid people with foot problems as well as the impact “orthotics” can have on foot, knee, hip, and spine deformities. They are used by everyone from athletes to the elderly to accommodate biomechanical deformities and a variety of soft tissue inflammatory conditions such as plantar fasciitis.[8]   wikipedia.org/Orthotics#Foot_orthoses

Medical Necessity

 

When Medically Necessary, benefits are available for:

  • Orthotics (braces, boots, splints) for foot disfigurements resulting from bone deformity, motor impairment, paralysis, or amputation. This includes but is not limited to, disfigurement caused by cerebral palsy, arthritis, polio, spina bifida, diabetes, accident, injury, or developmental disability, and
  • Podiatric devices, such as therapeutic shoes and shoe inserts, to prevent or treat diabetes-related complications

Covered Services include determining if You need the device, initial purchase, fitting, adjustment, and repair of a custom made rigid or semi-rigid supportive device  Sample ACA/Obamacare Policy Page 77 

Clinical Policy Rules to get coverage

Aetna

Medicare

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies

 

Consumer Resources

 

San Pedro Shoes
Excellent Orthotics

spenco.com/ insoles

Video Istep digital foot analysis
vimeo.com

thorlo.com  Socks

Before AB 2012, health plans and insurers were required to offer group coverage for orthotic and prosthetic devices under terms agreed upon between the employer and the health plan or insurer. AB 2012 revised the existing “mandate to offer” to stipulate that this coverage may be subject only to maximums and limitations on coverage that apply to the plan’s basic health care services. The new provision is effective July 1, 2007.

 

Related Pages

 

What does an Orthotic look like?

What are Orthotics – Video

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