A Few Frequently Asked Questions About What Medicaid Covers
What coverage do pregnant women get under Medicaid?
Pregnant women are covered for all care related to the pregnancy, delivery and any complications that may take place during pregnancy and up to 60 days postpartum.
Pregnant women may also qualify for care that was received for their pregnancy before they applied and received Medicaid. Some states call this Presumptive Eligibility and it was put in place so that all women would start necessary prenatal care as early in pregnancy as possible. Pregnant women are usually given priority in determining Medicaid eligibility. Most offices try to qualify a pregnant woman within about 2-4 weeks.
Does Medicaid cover VSG?
Vertical sleeve gastrectomy, also known as VSG, is surgery to help with weight loss. Medicaid does not cover weight loss surgery in most cases. However, it is best to check with your state on an individual basis to confirm that they do not offer it as a benefit separate from mandatory federal benefits.
Does Medicaid cover dental services?
Medicaid pays for emergency and medically necessary dental work across the country. Medicaid also pays for comprehensive dental care in more than 30 states. However, others may only cover certain categories of treatments. Medicaid does cover dental services for all child enrollees as part of the Early and Periodic Screening, Diagnostic and Treatment benefit. Check with your state to see what your exact level of dental coverage is.
What does Medicaid cover for children?
Who Prescribes The Shoes And Inserts
The shoes and inserts must be prescribed by a Podiatrist , which is a foot doctor, or other qualified healthcare provider these may be a physician assistant, nurse practitioner, or clinical nurse specialist.
Once you have the Statement of Certifying Physician from the physician who is treating you for diabetes, you then need to see a podiatrist or other qualified health care provider for the correct prescription.
The Prescribing Practitioner is the one who will write the order for the therapeutic shoes, modifications and inserts.
Again, please remember that the Prescribing Practitioner the Podiatrist, or other qualified healthcare provider, who gives you the prescription for the shoes and inserts must be Medicare-enrolled, otherwise you will not receive your Medicare coverage.
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Submitting Claims After Par Approval
Providers must receive an approval for all items/services that require a prior authorization before submitting a claim.
Once prior authorization is received, claims should only include the approved PAR number and, if applicable, the serial number of the approved equipment. In most cases, it is not necessary to submit a copy of the approved PAR. Providers will be notified if a copy of the approved PAR is needed.
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Does Medicare Cover Orthopedic Shoes
Medicare coverage of orthopedic shoes is generally limited to people with diabetes and severe diabetic foot disease. Medicare Part B may cover the fitting and purchase of either one pair of custom-molded orthopedic shoes and inserts each calendar year or one pair of extra-depth orthopedic shoes each calendar year. Medicare may also cover shoe modifications instead of inserts. In addition, Medicare may cover two additional pairs of inserts each calendar year for custom-molded shoes and three pairs of inserts each calendar year for extra-depth shoes. Even if you have diabetes, a doctor such as a podiatrist, must certify that you need orthopedic shoes or inserts. Further, your orthopedic shoes or inserts must be supplied by an orthotist, prosthetist, pedorthist or other qualified individual trained in treatment of the conditions of the foot and ankle.
If your supplier accepts Medicare assignment, you generally pay 20% of the Medicare-approved amount and the Medicare Part B deductible applies. Your doctors and suppliers also must be enrolled in Medicare for Medicare to provide coverage for your orthopedic shoes.
Does Medicare Cover Orthotics And Podiatry
Podiatrists may prescribe foot orthotics such as a shoe insert to treat foot problems caused due to arthritis, bunions, bursitis, plantar fasciitis, tendinitis, arch or heel pain or diabetic foot ulcers.
Medicare categorizes orthotic devices under the durable medical equipment benefit. Medicare Part B would cover 80% of the approved costs of orthotic devices when it is recommended by the podiatrist.
The device can be pre-made or custom-made depending on the case. The coverage would be provided only when the podiatrist feels the device is medically necessary to support the recovery of the patient or to avoid further complications.
Durable medical equipment is the device that can be used for healthcare purposes usually at home. These devices have a life expectancy or durability of more than 3 years.
The costs of orthotics would be covered by Medicare part B benefit when it fulfills the criteria for the device to be durable medical equipment. Also, the equipment should not be useful to anyone who is not sick or injured.
Medicare part B has listed the following devices as orthotics under the category of DME:
- Prosthetic devices such as artificial limbs
- Bracing for ankles, back, neck, foot, knee, spine, hand, elbow, and wrist
- Orthopedic shoes when they are a necessary part of the leg brace
- Other prosthetic devices such as artificial eyes
Medicare recipients have to meet all the following prerequisites to be eligible for coverage:
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How To Apply For Medicaid
Because Medicaid is administered through the state and states determine eligibility, you will need to visit your state’s Medicaid office or website to apply. When applying you will need proof of income, residency, age, citizenship and/or immigration status for every member of your household.
Contact your state Medicaid office . Getting approved for Medicaid can take time, so start the application process as soon as there is a clear need. Most offices allow you to apply or at least start your request online. You may need to go into one of their offices for an interview as part of the application process. Have all your needed verification documents ready.
Medicaids Eligibility factors include income, residency, age, citizenship, immigration status, household composition, and pregnancy.
The exact verification documents you will need will vary based on what state you are in. However, be prepared to have any proof of income, proof of residency, your social security card, and immigration status confirmation documents on hand . Generally, household composition and pregnancy status do not require formal verification.
How To Get Help With Medicare Coverage For Diabetic Shoes
If you have diabetes and need therapeutic shoes, your doctor can help get you started. When you add Medigap coverage, you can be doubly assured your shoes wont break the bank.
Your Medigap plan can help with coinsurance, copays, and your Part B deductible. Our agents can help find the best options for you. Call us today for a quote in minutes! Or, if you prefer, you can complete an online rate form, and a member of our team will reach out to you.
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Understanding Medicare Coverage Of Shoe Orthotics
Now, to answer the question of whether Medicare covers shoe orthotics: Original Medicare generally pays 80 percent of the Medicare-approved cost for shoe orthotics, therapeutic shoes, and shoe inserts after you have met your deductible after that, youll only be responsible for the remaining 20 percent.
If your Medicare doctor decides orthotics are medically necessary for you and prescribes them to you, Medicare Part B, medical insurance, may cover 80 percent of the approved costs as long as you buy the orthotics from a prescriber that participates in Medicare.
To recap, you must meet the following two conditions:
- Your Medicare doctor has decided shoe orthotics are medically necessary for you.
- You purchase your shoe orthotics from a Medicare-participating supplier.
Now we will get a bit detailed with the terms of the benefits:
Shoe orthotics are categorized by Medicare as Durable Medical Equipment or DME. They may also be classified as Durable Medical Equipment Prosthetics, Orthotics, & Supplies or DMEPOS. Your shoe orthotics may fall under the DME or DMEPOS benefit which means Medicare will generally cover 80 percent of the approved costs. Again, this is only when your Medicare doctor has recommended them for you or prescribed them to you and only when you get the shoe orthotics from a Medicare-participating supplier.
> > Questions about your Medicare coverage? Contact Cano Health at 855.CANOMED to speak with a Benefit Coordinator.
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How Much Does Medicare Pay For Orthotic Services
Podiatrists are doctors who specialize in the feet and ankles, and they prescribe and design medically orthotic devices. Orthopedic devices as part of a leg brace fall under Medicares guidelines for durable medical equipment .
In order for Medicare to cover orthotics, your doctor must first determine that orthopedic care is medically necessary. Medicare Part B may cover about 80 percent of the Medicare-approved cost, and you may have to pay the remaining co-insurance. The company that supplies your DME must be Medicare-approved.
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Does Medicare Cover Orthotic Shoes Or Inserts
Orthotic shoes are custom-fitted footwear designed to reduce the patients pain for a variety of health conditions including:
Metatarsalgia: chronic pain in the ball of the foot
Plantar fasciitis: chronic breakdown of soft tissue around the heel
Bunions: a painful, bony bump on the outside of the big toe
For the most part, Medicare does not cover orthopedic or inserts or shoes, however, Medicare will make exceptions for certain diabetic patients because of the poor circulation or neuropathy that goes with diabetes.
Medicare may cover the fit and cost of one pair of custom-fitted orthopedic shoes and inserts once per year for those patients.
Modifications Of Stock Shoes
Shoe modifications can be classified as internal or external .
Internal shoe modifications:
Long medial counters:
Interior heel wedges:
External shoe modifications:
Shoe wedge is any device, generally constructed of leather that is placed on the side of the walking surface of a shoe or within the shoe construction itself, and not in direct contact with the foot. The purpose of a shoe wedge is to re-distribute the flow of weight through the foot.
First Metatarsal Head is a wedge that extends on the medial side of the shoe from the breast of the heel to the first metatarsal head.
Full Lateral is a wedge on the outer side of the shoe extending from the heel to the tip of the shoe.
Full Medial is a wedge on the medial side of the shoe, extending from the heel to the tip of the shoe.
Lateral Dutchman is a wedge that is placed on the lateral margin of the sole of the shoe.
Medial Dutchman is a wedge that is placed on the medial side of the sole of the shoe.
Medial Tip is a wedge placed on the medial side of the tip of the sole of the shoe.
Flanges or flare outs are 0.25-inch wide medial or lateral extensions of the sole or heel that provide rotatory stability. A lateral flange provides a lever-arm, which ensures a foot flat in the presence of excessive inversion or varus deformity. Such small lateral flanges are seen on most commercially available runner’ shoes.
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Therapeutic Shoes As Integral Parts Of A Leg Brace
Note: Even under plans that exclude coverage of foot orthotics, Aetna covers therapeutic shoes if they are an integral part of a covered leg brace and are medically necessary for the proper functioning of the brace. Oxford shoes are usually covered in these situations. Other shoes, e.g., high-top, depth inlay or custom-molded for non-diabetic, etc., may also be covered if they are an integral part of a covered leg brace. Medically necessary heel replacements, sole replacements, and shoe transfers are also covered for therapeutic shoes that are an integral part of a covered leg brace. Inserts and other shoe modifications of shoes that are an integral part of a leg brace are covered if they are medically necessary for the proper functioning of the brace. Medically necessary shoe and related modifications, inserts, and heel/sole replacements, are covered when the shoe is an integral part of a leg brace. A matching shoe, which is not attached to the brace and items related to that shoe, are also covered.
Shoes that are billed separately will not be covered even if they are later incorporated into a brace.
How Much Do Custom Orthotic Inserts Cost
Custom-molded shoes and inserts can cost hundreds of dollars per pair. While this might seem a lot more expensive than over-the-counter manufactured options, the cost isnt that much different when you factor in Medicare or insurance coverage. A custom pair of orthotic shoes can cost between $400 and $600. Medicare beneficiaries will pay 20% of the cost after meeting their annual deductible, and Medicare will pay 80%. This means that for a $600 orthotic, you would pay $120, while Medicare pays $480, if you have already satisfied your Part B deductible.
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Dates Of Service After The Death Of A Health First Colorado Member
Health First Colorado will reimburse supply providers for durable medical rental equipment, oxygen, and bulk supplies that are drop-shipped to the member’s home for services rendered during the month of the member’s death, only if the claims date of service is before the members date of death. Health First Colorado will make recoveries for all DMEPOS services following the date of the member’s death.
The interChange operationalizes this policy in the following ways:
- If the claim’s ‘date of service’ occurs before the member’s ‘date of death’ within the same month, the claim will be paid and not recouped.
- If the claim’s ‘date of service’ occurs on/after the member’s ‘date of death’ within the same month, and for all following months, the claim will be denied or eventually recouped.
Span Billing for Certain Supplies
The following items may have a date span of up to 30 calendar days on claims submitted to the Department:
- Diabetic testing supplies
- Continuous passive motion devices
- Parenteral and enteral nutrition
- Parenteral and enteral administration kits
- External infusion pump supplies
Determining Coverage For Orthotics
Does Medicaid cover orthotics? Now that you know that the answer depends on where you live, it’s important to know how to determine if your specific plan covers orthotic devices. If you’re not sure, call your state’s Medicaid office and ask about coverage for prosthetics, orthotics and similar services. When you enrolled in Medicaid, you may have received a booklet or packet of paperwork with coverage details. Review the information carefully to determine if orthotics are covered.
If you have a private health insurance plan, look at your plan’s summary of benefits and coverage . The SBC won’t list every possible service covered under the plan, but it will tell you if the plan covers durable medical equipment. Reviewing the SBC can also help determine how much you can expect to pay in copays, coinsurance and other out-of-pocket costs.
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Maximum Allowable For Rental
Fee schedule: With the exception of oxygen and items noted as continuous rental, rental reimbursement caps at the item’s purchase price.
MSRP or By Invoice Pricing: Fee schedule items that require manual pricing for rental, excluding oxygen, are reimbursed using the MSRP or Invoice methodology, divided by 13, for one month of rental. If for a partial month rental, divide again by 30 for the daily maximum allowable. Total rental reimbursement cannot exceed the maximum allowable purchase price.
If I Dont Have Medicare What About Medicaid
Medicaid programs are funded both federally, and by each individual state.
Consequently, each individual state has quite a lot of room for change with regard to what it does on its Medicaid programs, so long as it stays within the Medicaid guidelines.
In the case of Therapeutic shoes and inserts, you dont have to worry, as Medicaid covers them if you are eligible for Medicaid.
If you have Medicaid to qualify for the Diabetic shoes and inserts you must be diagnosed with diabetes and, as with Medicare have one of the following foot conditions
- history of foot amputation
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