Medicare Reimbursement Directly To The Patient
If the local prescribing physician does not accept Medicare assignment, and there is not a local qualified provider that does, the patient has the option of paying the provider the entire amount, and then applying for reimbursement directly from Medicare for 80% of the allowable amount. The Centers for Medicare & Medicaid Services will reimburse 80% of the amount it designates as “allowable, and the patient is responsible for paying 20% of the total payment amount. In order to qualify for coverage the patient must be fitted by a qualified provider, so it is not possible for a patient to purchase footwear directly from a manufacturer or a retail facility or online e-commerce store and then request the 80% reimbursement from Medicare.
NOTE: Some Medicare suppliers may not accept assignment if the allowable amount is too low to cover the appropriate materials and services. In these situations, the total cost to the patient may be higher than the allowable amount. If so, the patient may be expected to pay the Medicare supplier in full before he or she receives reimbursement from Medicare.
Can Medigap Help Cover The Cost Of Diabetic Shoes
A Medigap policy may be just what you need to help cover your diabetic shoes. Medicare Supplement plans are a great asset in helping cover extra costs. And a Medigap policy can help cover the out of pocket expenses you may have when getting diabetic shoes. Be aware that different Medigap plans have different coverages, so youll want to be sure you have the best policy.
What Are Diabetic Shoes
Diabetic shoes are shoes that are especially designed to protect the foot of a diabetic. The shoes often have a large “toe box” that allows movement of the toes and prevents the toes from being squeezed or chafed by the shoes. The shoes also often come with special insoles that help to prevent sores and prevent pain. The entire shoe is designed to distribute weight as evenly and comfortably as possible across the entire sole of the foot. This again prevents chafing and helps the foot to support the body’s weight. Diabetic shoes are also designed for maximum ventilation so that the feet can breath. Letting air into the shoe prevents the foot from overheating and swelling. The most advanced types of shoes are actually molded to the person’s feet. The insoles as well as the shoes themselves are custom designed to take into account the shape of the feet.
Diabetic shoes must be professionally fitted. A podiatrist usually does diabetic shoe fittings. Special diabetic shoes are often made of canvas so that the shoe is able to breathe. Sometimes more than one pair of shoes and insoles is needed to accommodate changes in weather and the seasons.
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Will Medicare Reimburse You For The Cost Of Your Shoes
- Your treating physician must complete a certificate of medical necessity for the shoes and document the need in your medical records.
- The shoes and inserts must be prescribed by a podiatrist or other qualified doctor and provided by a podiatrist, orthotist, prosthetist, or pedorthist.
Medicare To Allow Nurse Practitioners And Physician Assistants To Certify The Medical Need For Diabetic Shoes In Limited Circumstances
AOPA, in collaboration with other healthcare organizations, has actively supported the inclusion of nurse practitioners and physician assistants to serve as certifying practitioners under the Medicare diabetic shoe benefit. The Social Security Act states that the certifying physician must be the MD or DO that is managing the patients systemic diabetic condition. This has led to significant access issues as the delivery of healthcare has evolved and non-physician practitioners have become more prevalent as primary care providers.
The Durable Medical Equipment Medicare Administrative Contractors recently announced two separate pathways that expand the ability of NPs and PAs to certify the medical need for diabetic shoes provided to Medicare beneficiaries.
The first pathway only applies to NPs and is being coordinated by the Center for Medicare and Medicaid Innovation through the Primary Care First demonstration project. The PCF demonstration project will be implemented on January 1, 2021 and will run through December 31, 2025. NPs that are participating in the PCF demonstration project in one of the 26 states/regions that it will be implemented in may serve as the certifying practitioner for diabetic shoes covered by Medicare. The PCF model does not require the NP to operate under the direct supervision of a physician, but it does not apply to physician assistants. The announcement of the expansion of the role of NPs under the PCF demonstration project may be viewed HERE.
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Medicare Guidelines For Diabetic Shoes And Inserts
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A pedorthic device is created to treat a variety of possible foot-related problems such as congenital deformity, improper walking and partial foot amputations. If you are covered by Medicare Part B, you qualify for therapeutic shoes and/or inserts. Medicare coverage can help prevent suffering while saving you money!
Medicare Part B covers one pair of therapeutic shoes and/or inserts and one fitting each calendar year. If you qualify, you are limited to one of two types of the following shoes each year:
- One pair of depth-inlay shoes and three pairs of inserts
- One pair of custom-molded shoes if you cant wear depth-inlay shoes because of a foot deformity, and two addition pairs of inserts.
In order for Medicare to cover the cost of your therapeutic shoes, the doctor treating your diabetes must verify that you meet three conditions:
Medicare also requires that:
- Your doctor confirms your need for therapeutic shoes or inserts.
- A podiatrist or other qualified doctor prescribes them.
- Your items are provided by a podiatrist, orthotist, prosthetist or pedorthist
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What Type Of Shoes And Inserts Does Medicare Give Coverage To
If you have Medicare Part B and you have met all the Medicare conditions to qualify for shoes and inserts for diabetes,
The types of shoes that are covered each year include one of these:
- One pair if depth-inlay shoes and 3 pairs of inserts
- One pair of custom-molded shoes if you cant wear depth-inlay shoes because of deformity, and 2 additional pairs of inserts
Note: In certain cases, Medicare may also cover separate inserts or shoe modifications instead of inserts.
The source of the text is again Medicare Coverage of Diabetes Supplies, Services, & Prevention Programs which you can read or download here.
What Am I Looking For In Orthopedic Shoes
According to the Mayo Clinic, when shopping for orthopedic shoes look for:
- Support and flexibility in the sole
- A large toe box
- A reasonable cushion that creates padding between your foot and the ground
Shoes that are too tight, too small and dont give enough support can cause pain and other problems such as injuries and deformities.
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Medicare Advantage & Orthotics: What Is Covered
If you are enrolled in a Part C, or Medicare Advantage plan, the private insurer responsible for administering the plan may offer enhanced benefits beyond Medicare’s coverage for foot orthotics. If you’re unsure what is covered, you should speak with your provider and refer to your plan’s benefits coverage details.
What Does Medicare Diabetic Shoe Coverage Include
Medicare coverage for Diabetic shoes comes under the Durable Medical Equipment Clause of Original Medicare Part B. You must either be signed up for Part B or have an Advantage Plan. Medicare recipients with an Advantage Plan should read the plan specifications related to diabetes before choosing the plan to make sure that they can easily meet the rules and guidelines for diabetics. Under Original Medicare the patient pays 20% of the cost of the shoes and insoles.
Medicare coverage includes one pair of regular diabetic shoes and three pairs of custom fitted insoles per year. If a Medicare recipient has deformed feet and they are unable to be properly fitted to wear standard diabetic shoes, Part B will cover 80% of the cost for molded custom shoes and three pairs of insoles a year.
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Does Medicare Cover Diabetic Shoes
For those with diabetes, special shoes can offer much needed help with foot pain, circulation and more. The costs of these diabetic shoes can add up so its natural to try to get insurance to cover them.
This leads to the question many have which is does Medicare cover diabetic shoes? Below we answer this question, look at the costs of diabetic shoes as well as some other helpful info.
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Medicare’s Therapeutic Shoe Benefit
The Centers for Disease Control and Prevention estimates that 23.1-million Americans have been diagnosed with diabetes. Studies have shown that 25 percent of persons with diabetes develop foot problems related to the disease and that up to 15 percent of persons with diabetes develop foot ulcers.
Since 1993, Medicare has covered certain therapeutic shoes, inserts and modifications for persons with diabetes who meet specified qualifying requirements.
Medicare covers diabetic shoes, inserts and modifications for program beneficiaries only if the following criteria are met*:
The patient has diabetes and one or more of the following conditions:
- Previous amputation of the other foot, or part of either foot, or
- History of previous foot ulceration of either foot, or
- History of pre-ulcerative calluses of either foot, or
- Peripheral neuropathy with evidence of callus formation of either foot, or
- Foot deformity of either foot, or
- Poor circulation in either foot
The patient has a prescription for a particular type of footwear from a podiatrist or physician who is knowledgeable in the fitting of diabetic shoes and inserts.
A “Statement of Certifying Physician for Therapeutic Shoes” from a physician who manages the patient’s diabetes, which certifies that the patient has diabetes mellitus, has at least one of the qualifying conditions , is being treated under a comprehensive plan of care for his or her diabetes, and needs diabetic shoes.
Lets Talk Diabetic Shoes
Did you know..
that people with diabetes and neuropathy could be entitled to one pair of diabetic shoes, per year? Medicare Part B may cover 80% of the cost of the diabetic shoes, when specific requirements are met. And, if there is a secondary Insurance, the secondary may pick up the remaining 20%. Some other insurance programs also participate in a coverage of yearly diabetic shoes as well.
What is a Diabetic Shoe?
The word diabetic shoe seems to form an image in our mind of a large clunky shoe. But thats not true – diabetic shoe styles have come a long way! There are choices now in color and style just like regular shoes, as well as attractive and fun socks. Yes, socks! The sock is just as important as a proper fitting shoe. A diabetic sock should have a seamless toe and have moisture wicking with padded forefoot and heel for true comfort. It is very important that the sock doesnt wrinkle or bunch in the shoe, as this could cause sores. A diabetic shoe should have a firm sole and be slip resistant and is specially constructed to protect the foot. They are extra-depth to accommodate special inserts and keep the top of the shoe from rubbing on the top of the foot. The special inserts will either be heat moldable or custom made. The insert type will be determined by your doctor for your needs.
How We Can Help
Diabetic Shoes are only one part of Good Foot Care
Remember, it is not only the good shoes
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To Find A Supplier/qualified Provider For Your Shoes And Inserts
If your treating physician doesnt point you in the right direction, here are some tools to locate qualified providers/suppliers for your shoes and inserts.
To find a Podiatrist you can use the locator tool on the American Podiatric Medical Association website here.
To find a Pedorthist you can use the locator tool on the Pedorthic Footcare Association website here.
To find a Prosthetist you can use the locator tool on the Prosthetist Finder website here.
To find an Orthotist you can use the locator tool on the American Board for Certification in Orthotics, Prosthetics and Pedorthics here.
Obviously you can use the last locator to find Pedorthists and Prosthetists as well as Orthotists.
Remember to only use Medicare-approved suppliers and those who accept assignment !
Diabetic Shoes Things To Know
We offer a wide selection of diabetic shoes from Dr. Comfort, Apex and Orthofeet..
What are diabetic shoes?
Diabetic shoes, sometimes referred to as extra depth, or therapeutic shoes, are specially designed shoes intended to reduce the risk of pressure and or skin breakdown in those suffering from diabetes. These shoes have a wider and deeper toe box compared to traditional shoes . The primary goal of diabetic footwear is to prevent foot complications, which can include strain, ulcers, callouses, or even amputations for those poor circulation related to diabetes. These shoes are manufactured under strict guidelines and they must be equipped with a removable orthotic. The shoes and insoles work together as a preventative system to help provide joint stability, prevent joint deformity , and improve overall mobility.
Do I need a prescription?
The purchase of diabetic shoes does not require a prescription. However, insurance company guidelines require that diabetic shoes be prescribed by a physician and fitted by a qualified individual such as a Certified Orthotic Fitter. Here at Aston Pharmacy, we have a Certified Orthotic Fitter to meet all of your diabetic shoe needs.
Will insurance or Medicare cover diabetic shoes ?
Most insurance companies will cover part or all of the cost of diabetic shoes and insoles. Each insurance company has their own requirements for coverage. Here a few guidelines:
Medicare and Keystone 65 –
Blue Cross/Blue Shield and other Commercial insurances–
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How Do I Know If I Am A Candidate For Diabetic Shoes Or Inserts
If your current footwear seems uncomfortable, regardless of how long theyre worn or the distance you walk, you might be a candidate for diabetic shoes. Simply being diagnosed with diabetes isnt enough on its own to warrant the need for specialized footwear, so your best bet is to visit with your doctor and a foot orthotics specialist. In order to be fitted for shoes by one of our practitioners, you must be referred by your physician, so schedule an appointment with them to talk about your options.
Medicare Rules And Coding For Diabetic Patient With Amputation
Question:For Diabetic patient with amputation, if requirements are met documentation-wise, are patients entitled to ONE pair of shoes, and diabetic orthotics with met/toe fillers per ONE year? And what codes would be billed?
Answer:According to NHIC DME MAC A Listserve of June 8, 2012 featured below, Medicare clarified eligibility for L5000, Partial foot with longitudinal arch, toe filler.
If foot missing hallux or forefoot, arch support with filler understood to require additional rigidity than foot insert without filler and can be billed as L5000. Medicare allows coverage for a single L5000. If patient has diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts.
If foot missing lesser digit, arch support with filler NOT assumed to require additional rigidity than foot insert without filler and CANOT be billed as L5000. If patient HAS diabetes, they may quality for up to either three single A5512 prefabricated heat molded inserts or up to three single A5513 custom molded inserts. If patient DOES NOT have diabetes, partial foot, shoe insert with longitudinal arch, toe filler can be billed as L5000 only if beneficiary missing hallux or forefoot. It is not appropriate to billing either L5000, A5512 or A5513 is patient does not have diabetes and is missing lesser digit only.
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