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Does Medicare Pay for Braces?

Medicare Part B (Medical Insurance) covers medically necessary arm, leg, back, and neck braces under the durable medical equipment (DME) prefabricated orthotics benefit. All individuals who have Medicare Part B are eligible for this benefit. Likewise, those who have Part B benefits through a Medicare Advantage plan would also be eligible for this coverage.

Part B of Medicare covers medically necessary durable medical equipment that your doctor prescribes for use in your home. Only your doctor can prescribe medical equipment for you. Durable medical equipment (DME) meets the following criteria:

  • Durable (i.e., long lasting)
  • Used for a medical purpose
  • Not typically useful to a person who is not sick or injured
  • Used in your home

When covered for a brace, Medicare enrollees would be responsible for paying 20 percent of the Medicare-approved amount for their braces. In addition, the annual Medicare Part B deductible would also apply in this case. In 2015, the amount of the Part B deductible is $147.

Medicare will only cover your DME if your doctor and DME supplier(s) are enrolled in Medicare. Doctors and suppliers must meet strict standards in order to enroll and remain enrolled in Medicare. If your doctors or suppliers are not enrolled, Medicare will not pay the claims that are submitted by them.

It is important to ask your suppliers if they participate in Medicare prior to obtaining your durable medical equipment. If they are participating suppliers, then they must accept Medicare assignment. If suppliers are enrolled in Medicare, but they are not “participating,” then they may choose not to accept assignment. If a supplier does not accept Medicare assignment, then there is no limit on the amount that they can charge you for your DME.

Obtaining a Brace Through the Competitive Bidding Program

In January 2011, Medicare began a new Competitive Bidding Program for certain types of durable medical equipment, prosthetics, orthotics, and supplies in nine areas of the country. In January 2013, Medicare expanded the Competitive Bidding Program even further throughout the country. This program changes the amount that Medicare pays for certain medical equipment and supplies. It also makes changes to which suppliers that Medicare will pay to supply these items to you.

Under this program, suppliers submit bids to provide certain medical equipment and supplies. Medicare then uses these bids to set the amount that it will pay for those equipment and supplies under the Competitive Bidding Program. Qualified, accredited suppliers with winning bids are chosen as Medicare contract suppliers.

This program can help both you and Medicare to save money. It can also help to ensure that you have better access to quality medical equipment, supplies, and services from suppliers that you can trust. In addition, the program helps in limiting fraud and abuse in the Medicare program.

How to Determine the Amount of Your Brace

In order to determine how much your specific brace will cost, you should talk with your doctor or other health care provider. The amount that you owe may depend on several factors, such as any other insurance that you may have, how much your doctor charges, whether your doctor accepts Medicare assignment, and the location where you obtain your item from.

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