The American health care system sucks. I can only imagine how hard it must be for someone with a chronic illness such as diabetes. It’s bad enough you have to inject yourself with insulin and constantly check your blood sugar and always watch what you eat. For some diabetics, foot problems crop up that require special orthopedic footwear.
Fortunately, your medical insurance provider might be able to recoup at least some of the cost. You may not even have to pay anything out of pocket! Of course, certain deductibles, co-insurance, and co-payments may apply. Your situation may vary from another’s.
You will almost certainly require proper documentation from a doctor. Diabetic shoes and inserts are indeed covered under Medicare, Medicaid, and most insurance policies. However, there are certain criteria to be met. Your health care provider must fill out a therapeutic shoe form.
Typically, if you qualify for the shoes and have met your deductible, Medicare will pay up to eighty percent of the cost. Some secondary insurers may help with the other twenty percent.
Do I Even Need These Shoes?
Don’t be like Bill Dauterive from King of the Hill and pay for a wheelchair and renovations that you don’t need! Every diabetic’s condition is different. Assess what yours is. Do your present shoes fit comfortably? If your present footwear fits uncomfortably, no matter how long they have been worn or how far you walk, you may be a candidate for diabetic shoes.
Merely being diagnosed with diabetes is not enough by itself to warrant the necessity for special footwear. With this in mind, your best course of action is to consult with your doctor and a specialist in foot orthotics. It is often required that before you can be fitted for shoes by a licensed practitioner you must be referred by your physician. For that reason, you should schedule an appointment with these people to discuss all available options.
The health care professional who treats your diabetes must be the one to certify your requirement for therapeutic shoes or inserts. The shoes and inserts must be prescribed by a qualified doctor such as a podiatrist. The shoes and inserts can be provided by one of the following.
- an orthotist
- a pedorthist
- a prosthetist
- a podiatrist
Could I Have a Brief Explanation of the Benefits?
According to the Center for Disease Control, about thirty million Americans have diabetes. Of this thirty million twenty-five percent of them will develop foot problems related to diabetes. Up to fifteen percent of diabetics develop foot ulcers. What’s more, studies show that prescription diabetic footwear can aid in preventing grievous foot health complications that can be the result of diabetes.
The cost of many types and brands of shoes and prescription inserts for diabetics who meet all of the criteria may be reimbursed by Medicare and supplemental insurance. Remember that only a qualified health professional can determine if you are eligible. If you are diabetic or have any major foot health concerns you are strongly encouraged to see a foot health professional to evaluate all of your foot health needs.
Am I Eligible?
Way back in May of 1993 (has it been that long?) Congress passed the Therapeutic Shoe Bill, known as TSB for short. The purpose of TSB is to provide reimbursement on therapeutic inserts, shoes and necessary modifications for beneficiaries who have diabetes and meet the very specific eligibility requirements.
You must have the appropriate documentation from a qualified physician, of course. If you are diabetic, are being treated under a comprehensive diabetes care plan and you need therapeutic shoes and/or inserts due to diabetes and have Medicare Part B you could qualify for coverage. Do remember that it is not simply enough to have diabetes. You must also have at least one of the following.
- Partial or complete amputation of the foot
- A history of ulcers
- A history of pre-ulcerative calluses
- Poor blood circulation
- Deformity of the feet
- Diabetic neuropathy with evidence of callus formation
- Nerve damage due to diabetes accompanied by signs of problems with calluses
Good News! I Have Medicare Part B!
That’s great! Medicare Part B covers the furnishing and fitting of one (1) pair of custom-molded shoes and inserts and one (1) pair of extra-depth shoes per calendar year, provided you are diabetic and have a severe foot disease as a result of diabetes: Medicare will also cover two (2) extra pairs of inserts each calendar year for custom-molded shoes and three (3) pairs of inserts each calendar year for extra-depth shoes. They will also cover shoe modification in lieu of inserts.
Uh…Just How Good is This News?
Does your supplier accept the assignment? If so, you will pay twenty percent of the Medicare-approved amount. Naturally, the Part B deductible will apply. Medicare will cover your therapeutic shoes only on the condition that your doctors and suppliers are also enrolled in Medicare.
Doctors and suppliers have to live up to stringent regulations in order to enroll and continue to be enrolled in Medicare. In the event that your doctors or suppliers are not enrolled, Medicare is under no obligation to pay the claims that they have submitted.
It is also of utmost importance to inquire of your suppliers if they participate in Medicare before you obtain therapeutic shoes. If said suppliers are indeed participating suppliers then they are obliged to accept the assignment. Should suppliers be enrolled in Medicare but are not “participating,” they may choose to opt-out of accepting the assignment. If suppliers do not accept assignment then there is no cap on the amount, they can charge you.
So, Tell Me More….
Your physician or other health care provider may suggest that you procure services more often than covered by Medicare. It is possible that they may call for services that Medicare does not cover. Should this happen, you might have to pay some or even all of the resulting costs.
Do not be afraid to ask questions so you may have a better understanding as to why your doctor is advising particular services and whether or not Medicare will pay for them.
In order to figure out how much your item, test, or service will cost you should speak with your physician or health care provider. The specific amount you will owe could depend on numerous things. You may have to consider the following circumstances.
- What kind of insurance do you have?
- How much does your doctor charge?
- Does your doctor accept the assignment?
- What type of facility are you getting your treatment from?
- Where did you get your service, test or item?
I’m Going to Need Some Paperwork, Aren’t I?
Yep. But, don’t sweat it. Most of the paperwork will be your doctor’s responsibility. You just have to keep up with it! (A school folder is highly recommended to keep everything organized.) The doctor treating you for your diabetes must be able to certify that you do indeed have diabetes.
It must also be certified that you have one or more of the foot problems listed after questioning your eligibility. You must also be under a comprehensive diabetes treatment plan and definitely need special shoes. Medicare does have a form for this certification. You will also require a prescription for the shoes.
Said prescription must come from a podiatrist or physician who knows how best to fit shoes and inserts for people who have diabetes. This prescription should indicate a particular type of footwear. The choices would include (but perhaps not be limited to) shoes, inserts, or modifications.
The footwear in question is required to be fitted and supplied by a podiatrist or other qualified personnel. That individual could be a pedorthist, orthotist or prosthetist. The certifying physician may not supply the footwear unless said individual practices in a specified rural area or area where there is a deficiency of health care professionals. The prescribing podiatrist can be the supplier.
Just What Makes Diabetic Footwear So Important?
Many diabetics suffer from chronic diabetic neuropathy. This is nerve damage that can make your feet vulnerable to injuries in quite a number of various ways. Based on the findings of the Nation Institutes of Health:
- Injuries can take a longer amount of time to heal properly when there is a restriction in the blood flow.
- Limbs can sometimes lose feeling. This can make it even more difficult to detect an injury
- Some patients might lose sensation in their feet. Thus, an injury can go unnoticed and result in an infection
The Center for Disease Control (CDC) strongly suggests quarterly foot exams for all diabetic patients. As well as regular exams, the CDC advises patients to keep their feet clean, inspect their feet for injuries, keep their toenails clipped carefully, and wear the proper socks and shoes.
The National Institutes of Health advocates keeping an open discourse with your doctor concerning your need for special diabetic shoes and/ or shoe inserts. There are quite a number of situations where diabetics might require custom-made shoes that offer additional protection.
Studies have shown that wearing prescription diabetic footwear can help prevent complications regarding foot health that can often occur due to diabetes. Should you need diabetic shoes, a sort of professional such as a podiatrist, orthotist, pedorthist or prosthetist is required to provide the prescription for therapeutic shoes.
Turns Out I Have Part A
If you have the Medicare Advantage plan, that means that you have coverage due to a private Medicare-approved insurance company. These plans should cover all that Original Medicare covers with an exception for hospice care, which is what Medicare Part A covers. (Let’s hope you won’t need that for quite some time.) Thus, if you are enrolled in a Medicare Part C Advantage plan you must have coverage on diabetic shoes if all of the eligibility conditions are met.
If you do not have any extra coverage to Medicare you might be eligible for enrollment in a Medigap policy that can aid in paying for the out-of-pocket expenses that are often associated with Medicare. A Medigap policy is practically identical to a Medicare Supplement.
While it does depend on the Medicare Supplement you opt to enroll in you may have very little to no out-of-pocket costs regarding your diabetic supplies. But do keep in mind that different letter plans pay for different amounts.
What Does This Mean for Me?
Should you be a Medicare Beneficiary with Medicare Parts A and B, have diabetes, and you have reasons for requiring diabetic shoes that could fall under “Medically Necessary“, you could very well be eligible. Do keep in mind that if you are only covered through Traditional Medicare, the costs that will fall under your responsibility will include meeting your Part B deductible and the twenty percent coinsurance.
If you have extra coverage, such as the Medicare Supplement plan, you could very well wind up spending less on diabetic supplies and services. If you are a Medicare beneficiary, you may want to think about enrolling in the Medicare Part D Prescription Drug plan. Prescription Drug plans can aid in covering the expenses of your daily diabetic prescriptions.
Some beneficiaries may perceive that the most helpful assistance available for them is in a Medicare Advantage plan. You are advised to speak with an insurance agent licensed in your state. This person will aid you in identifying the most advantageous and feasible plan for you.
So, How Do I Get Medicare?
You can call 1-800-MEDICARE at any time on any day to ask questions. Users of TTY can call 1-877-486-2048. You will be given a complete list of available plans and someone will be able to discuss your options with you.
Medicare supplement insurance is available if you are already enrolled in Medicare Parts A and B and are over the age of sixty-five. In some states, you may be eligible even if you are under sixty-five because of a disability.
Will Medicare Cover the Costs of my Foot Care?
Your podiatrist foot exams and treatment are covered by Medicare Part B should you have nerve damage related to diabetes or have a medical necessity for treatments of foot diseases or injuries such as hammertoe, heel spurs or bunion deformities.
It covers exams for diabetic peripheral neuropathy and loss of protective sensations every six months. You must not see a foot care professional for any other reason between visits. You would only pay twenty percent of the Medicare-approved amount.
The Part B deductible applies. If this is a hospital outpatient setting you would also pay a copayment for medically necessary treatment. Talk with your doctor or health care provider about the specific amount owed. Medicare does not generally cover the costs of routine foot care. (To put it bluntly, buy your own nail clippers, you cheapskate.)
Because the American government is convinced that socialized medicine is the Devil many diabetic patients rely on Medicare and other insurance to defray the costs of supplies, medications, doctor visits and of course specialized footwear.
You will have to consult with your health care provider to see if you qualify. Do not hesitate to ask any questions or bring up any concerns that you may have. Remember that you are your best health care advocate. Try to learn all of your options and determine which ones would be best for you.