Q and A: Everything You Need to Know to Avail the Medicare’s Diabetic Shoe Benefit

Diabetic foot is a chronic complication, the treatment for which is often prolonged and expensive. Thus, diabetic foot problem is not only detrimental to the well-being of a person but also puts a major financial burden on an individual patient. As a result, patients often need to rely on Medicare or commercial insurance to bear the cost. As a matter of fact, Medicare and commercial insurers do offer coverage for diabetes supplies like drugs, syringes, insulin pumps and so on, but does Medicare pay for therapeutic diabetic footwear? Read below to find out.

Q. Does Medicare pay for diabetic shoes?

A. Yes, Medicare does provide coverage for podiatry services, including diabetic shoes, inserts or orthotics. On May 1, 1993 the Therapeutic Shoe Bill was passed, which made it possible to have therapeutic diabetic shoes and inserts to be funded by Medicare for qualifying Medicare part B beneficiaries.

Q. What type of shoes and items are covered under Medicare’s Diabetic Shoe Program?

A. Medicare under its Diabetic Shoe Program strictly covers the following type of shoes and items:

  • Depth in-lay Shoes: These are full length shoes that provide at least 3/16 inch of extra depth to accommodate inserts. They are often made from leather or any other high quality suitable material.
  • Custom-molded shoes: These shoes are customized shoes that are fabricated using a replica model of the patient’s foot. They are often made from leather or any other high quality suitable material. They have removable inserts that can be altered or replaced as per patient’s requirement.
  • Inserts: There are multi-density, removable inlays that are custom-molded to fit the patient’s foot.

Q. Are diabetic shoes for women covered by Medicare?

A. As long as you are Medicare Part B beneficiary and qualify the eligibility criteria, Medicare will provide coverage for your shoes irrespective of the gender.

Q. I have diabetes and need new shoes. How to get free diabetic shoes from Medicare?

A. Remember that not everyone with diabetes needs diabetic shoes. But for those who are recommended to wear diabetic shoes, Medicare will provide them for free, well almost free.

Once the requirements concerning certification and documentation from the physician are fulfilled, Medicare will provide partial reimbursement for the diabetic shoe to the qualifying Medicare part B beneficiaries. The remaining expense has to be borne by the patient.

Nonetheless, the Diabetic Shoe Program is not just about getting a pair of free shoes. It is a preventive program aimed at preventing lower limb amputations in patients with diabetes as well as reducing the economic burden associated with the disease.

Q. How much will Medicare pay?

A. Medicare will pay 80% of the allowable amount (adjusted annually depending on the kind of footwear one needs) to Medicare part B beneficiaries.

Q. How much does the patient need to pay?

A. The patient is responsible for paying 20% of the Medicare approved amount, either through out of pocket or through the beneficiary’s secondary insurance.

Q. Is there any eligibility or qualifying criteria for the program?

A. As per Medicare guidelines, in order to be eligible for reimbursement the following qualifying conditions must be met:

I. The patients must have diabetes mellitus and

II. The patient must have at least one or more of the following mentioned six conditions in one or both feet

  • Loss of foot or part of either foot due to amputation
  • History of previous foot ulcers
  • History of previous pre ulcerative calluses
  • Established peripheral neuropathy
  • Foot deformity
  • Poor circulation and

III. The physician (who has diagnosed the patient and is managing his or her diabetic systemic condition) must certify that conditions I and II are met and the patient is being treated under a comprehensive diabetes care plan and that the patient has a medical necessity for diabetic shoes or inserts and

IV. The certifying physician must have a face-to-face evaluation with the patient within the last six months prior to the date of dispensing diabetic shoes or inserts

Q. What documentation is needed to initiate the reimbursement process?

A. For a qualifying beneficiary to receive the benefit, the following documentation is required in his or her medical record to certify the beneficiary’s eligibility:

  1. A written statement of certification, duly signed and dated by the certifying physician stating that the beneficiary has Diabetes Mellitus and
  2. An attested document from the certifying physician stating that the beneficiary has at least one or more of the above mentioned six conditions in one or both feet and
  3. A certification from the physician stating that the beneficiary is being treated under a comprehensive diabetes care plan and that the beneficiary has a medical necessity for diabetic shoes or inserts

Q. Once certification is done, how to get diabetic shoes through Medicare?

A. Following certification, once the eligibility of a beneficiary is established, a prescribing physician (not necessarily the certifying physician) or a podiatrist must write an order for diabetic shoes, inserts or modifications. The prescribing physician must then direct the patient to a supplier that accepts Medicare assignments. The supplier may be a podiatrist or any other qualified individual such as orthotist, pedorthist, or prosthetist. The supplier is responsible for fitting and furnishing the prescribed shoes, inserts or modifications and finally billing it to the Medicare on beneficiary’s behalf.

The certifying physician may not prescribe the diabetic shoes unless he or she is the only qualified individual available in the area. Also, a new certification statement by the physician will be required every year for furnishing and fitting of the diabetic shoes, modification, or inserts.

Q. What all is provided under Medicare Coverage?

A. Medicare offers limited coverage of therapeutic footwear and inserts. Only after the eligibility criteria and Medicare requirements are met, the beneficiary will receive the following in a calendar year (January – December):

  1. One pair of depth in-lay shoes and three pairs of shoe inserts or
  2. One pair of depth in-lay shoes with a modification and additional two pairs of shoe inserts or
  3. One pair of custom-moulded shoes (including shoe inserts) and additional two pairs of shoe inserts. Custom-molded shoe will be covered only if the beneficiary has foot anomaly

Apart from these, Medicare may also covers and dispenses shoe modifications or separate inserts independent of diabetic shoes if the supplier of the shoes confirms in writing that the patient has appropriate shoes (meeting Medicare’s specific definition) into which the shoe inserts can be fitted. However, Medicare under no circumstance will pay for any deluxe feature such as a custom material, colour or style in the shoe.

Q. Apart from Medicare, does private insurance provide coverage for diabetic shoes?

A. Patients must know that Medicare is not the only avenue to receive help to pay for diabetic shoes. There are multiple private insurance plans available that will cover the cost of diabetic shoes. A patient can verify whether the coverage is available or not with the help of medical billing code before proceeding with the podiatry services. There are several insurers who follow Medicare guidelines and may even pay up to 80% of the shoe cost.

Q. Are there any instances of diabetic shoes being denied by Medicare?

A. For patients who do not qualify the eligibility criteria, diabetic shoes, inserts, or shoe modifications will be denied by Medicare as non-covered. Also, in cases where the patient has already received diabetic shoes in the present year do not qualify for shoes up until next year.

Lastly, Medicare will not pay for diabetic shoes if the beneficiary’s suppliers and doctors are not enrolled in Medicare.

Q. Is there any option of buying diabetic shoes through online retailers?

A. Several online retailers have identified the growing demand for diabetic shoes and have started offering a wide selection of therapeutic footwear to suit the needs of diabetic patients. So now patients have a convenient option of buying diabetic shoes through online retailers or e-commerce stores. You can identify these shoes by the medical billing code A5500 which means that they are for diabetics only and Medicare approved.