Does Medicare cover back braces ?
Over the last year or so my mom’s back has been becoming very tired and rather hunched over, and mom and I have been discussing what she can do about this. One of the options is back braces, so I started to take a tentative look at what’s out there. And then I wondered …
Does Medicare cover back braces ? Yes, Medicare Part B typically gives 80% coverage to “medically necessary” back braces under the durable medical equipment prefabricated orthotics benefit, if they have been prescribed by a Medicare-approved doctor. If you can’t get coverage under Medicare you may be able to get help under other state funded programs for the elderly and disabled.
To get coverage for a back brace, as I have already said, you will first need to obtain a signed prescription from a Medicare-enrolled doctor, stating that a back brace is “medically necessary”.
Medicare has guidelines about when coverage may be given to a patient for a back brace.
The following text is from Medicare’s guidelines for back braces, which they are calling “Spinal Orthosis”
“A spinal orthosis (L0450 – L0651) is covered when it is ordered for one of the following indications:
1. To reduce pain by restricting mobility of the trunk; or
2. To facilitate healing following an injury to the spine or related soft tissues; or
3. To facilitate healing following a surgical procedure on the spine or related soft tissue; or
4. To otherwise support weak spinal muscles and/or a deformed spine.
If a spinal orthosis is provided and the coverage criteria are not met, the item will be denied as not medically necessary.”
In short, if you are to get coverage, the back brace has to be used to do one of the following –
- to reduce pain by restricting movement of the torso
- promote with the healing of the spine or muscles, ligaments after an injury, or after surgery
- give support to a weak spinal muscles and/or a deformed spine
What type of back brace are you allowed ?
Medicare will only cover rigid or semi-rigid braces of any type.
The two following exerts were taken from the Medicare Benefit Policy Manual, Chapter 15-
“A brace includes rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”
The text goes on to say
“Back braces include, but are not limited to, special corsets, e.g., sacroiliac, sacrolumbar, dorsolumbar corsets, and belts.”
There are many back braces to choose from, and of course your Medicare-enrolled doctor will advise you on that.
Some of the more popular brands are –
You will though have to get your brace from a Medicare-enrolled supplier, and he will have the brands he works with, so you may have to check out a number of suppliers.
How often will Medicare pay for a back brace ?
Medicare Part B replaces covered DME that are –
- worn out through use
- that have been in your possession for their entire lifetime
- so worn out that they can’t be fixed
- the minimum period considered to be a lifetime for DME is five years
- the lifetime can vary depending on the type of equipment
Typically, a back brace which is worn out can be replaced every five years, as long as it has been in the beneficiary’s possession for that whole period.
Medicare will pay to repair worn out items which don’t reach the end of their lifetime, but no more than the cost of a replacement.
When an item is replaced after 5 years, or when worn out, the claimant will go through the whole Medicare procedure again, starting with their Medicare-enrolled doctor.
How does Medicare decide on which equipment it will cover ?
Medicare calls the equipment that it covers for use in the home “Durable Medical Equipment”, or DME.
For equipment to qualify as Durable Medical Equipment it must –
- be able to withstand constant use over a sustained period of time – durable
- be for a medical reason only – not for comfort
- useful to someone who is actually sick, and of little use to a person who is well
- it’s primary use must be in the home
- it has to be able to last at least 3 years
How do you get coverage from Medicare Part B for DME ?
To get coverage from Medicare Part B for Durable Medical Equipment for “use in the home” –
- you need to be enrolled in Medicare Part B
- you need your Medicare-enrolled doctor to give you a signed prescription which states that the equipment is a “medically necessary”
- you need to purchase or to rent the equipment through a Medicare-enrolled supplier
Medicare defines “living at home” as –
- living in your own home
- living in the family home
- living in the community, such as assisted living
Now you have a signed prescription from your Medicare-enrolled doctor, what’s next ?
Now that you have your prescription –
- you will have to find a Medicare-enrolled DME supplier
- only go through a supplier who is a Medicare-enrolled “participating supplier who accepts “assignment’ – this ensures you pay only what you have to
- Medicare only gives coverage to pretty basic models of each equipment type, although you may sometimes be able to upgrade with certain DME by paying the difference yourself
- select your DME that you have been prescribed from the available choices
- sort out the necessary paperwork with the supplier – any forms etc
Medicare part B covers 80% of the Medicare-approved price for DME if you used a Medicare-enrolled supplier with a signed prescription from a Medicare-enrolled doctor saying that your item is “medically necessary”.
If you used a Medicare-enrolled “participating” supplier who accepts “assignment”, you will just have to pay your Medicare 20% co-payment of the Medicare-approved price for your DME, and your deductible if it applies.
Do get your item through Medicare-enrolled supplier who is a Medicare-enrolled “Participating” supplier who accepts “assignment”, if you don’t you can end up paying way too much.
Medicare will either rent or purchase DME – for the majority of equipment, and especially the pricier items, Medicare will rent from the supplier.
If your equipment is rented, you will just pay a 20% co-payment of the monthly rental, and if it applies your deductible at the outset.
Finding a local Medicare-enrolled DME Supplier near you
You can use this link to find a Medicare-enrolled supplier who is local to you – Medicare.gov
What if you have a Medicare Advantage Plan ?
Medicare Advantage plans cover at least everything offered by Medicare and sometimes, depending on the plan a little more.
In this case, as back braces are covered by Original Medicare, so they will also be covered by Medicare Advantage plans.
To find out which suppliers and doctors to use, you will need to contact you plan provider.
If you go outside your provider’s network you will doubtless lose coverage.
Durable Medical Equipment generally covered by Medicare if you qualify
If you don’t find the equipment you are looking for in my list of Medicare covered DME below, you can use this link to Mediace.gov
Alternating Pressure Pads and Mattresses
Audible/visible Signal Pacemaker Monitor
Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
Bed Side Rails
Bed Trapeze – covered if your loved one is confined to their bed and needs one to change position
Blood sugar monitors
Blood sugar (glucose) test strips
Canes (however, white canes for the blind aren’t covered)
Continuous passive motion (CPM) machines
Continuous Positive Pressure Airway Devices, Accessories and Therapy
Cushion Lift Power Seat
Digital Electronic Pacemaker
Electric Hospital beds
Gel Flotation Pads and Mattresses
Glucose Control Solutions
Infusion pumps and supplies (when necessary to administer certain drugs)
Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
Mobile Geriatric Chair
Nebulizers and some nebulizer medications (if reasonable and necessary)
Oxygen equipment and accessories
Patient lifts (a medical device used to lift you from a bed or wheelchair)
Postural Drainage Boards
Self-Contained Pacemaker Monitor
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
Urinals (autoclavable hospital type)
Whirlpool Bath Equipment – if your loved one is homebound and the pool is medically needed. If your loved one isn’t homebound Medicare will cover the cost of treatments in a hospital.
Prosthetic and Orthotic Items
Orthopedic shoes only when they’re a necessary part of a leg brace
Arm, leg, back, and neck braces (orthotics), as long as you go to a supplier that’s enrolled in Medicare
Artificial limbs and eyes
Breast prostheses (including a surgical bra) after a mastectomy
Ostomy bags and certain related supplies
Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.
Free one-on-one help with understanding Medicare
State Health Insurance Assistance Programs – SHIP – give free counseling about Medicare for people who need guidance.
SHIP counselors also give advice and help with Medicare Advantage, Medigap and Medicaid benefits.
It’s usually a phone service, but occasionally some of the programs may offer face-to-appointments as well.
If you want to find your local Medicare SHIP click here
How to contact a SHIP counselor in your state, step by step
Step 2 –
Click on a button to find your state – both buttons lead to the same menu
Step 4 –
You’ll get a new window with the contact info and phone number for you to call in your state
Does Medicaid cover back braces and other DME ?
Medicaid has a very different structure from Medicare, as its programs are funded both federally and by each individual state.
Concretely, this means that each individual state has quite a lot of leeway with what it does on its Medicaid programs, so long as it follows the Medicaid guidelines.
It is not uncommon for Medicaid to allow a state to waive some of its eligibility requirements for a program, so that a state may be able to give health care to people who might otherwise not get it.
When this is done it’s known as a Waiver, and each different waiver can have specific eligibility requirements targeting specific elements of the population, and often with limited places.
This has resulted in hundreds of waivers, all with different eligibility, and all across the US.
Care in the home – Medicaid and state programs
Programs primarily for low income families, the disabled and the elderly, which work to help them maintain their independence in their homes and in the community are called “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.
As part of helping the elderly participants to maintain their independence, HCBS programs and waivers, and 1915 waivers will all help to cover “home medical equipment”, and very often will cover it up to 100%.
If you would like to find out if you are eligible for an HCBS program or waiver, contact your State Medicaid Agency here.
You should also be able to find out more at your local Area Agencies on Aging.
Use the link below to find out more on HCBS programs or waivers –
Medicaid uses term “home” to mean any of the following –
- their own home
- their family home
- a group home
- an assisted living facility
- a custodial care facility
Programs and waivers which will likely cover more varied DME for “in home use”
HCBS programs and waivers working with “Consumer Direction”or “Self Direction”
“Consumer Direction”or “Self Direction” is essentially a money management model, where the program participant is largely in charge of how their program budget is spent. Each participant is given a budget so that they may manage their needs and live independently – to do so the participant will be given the help of an appointed a financial advisor.
If the participant being needs certain equipment to be part of the program or waiver, as long as the budget covers it, they will, more often than not, be able to get it.
Learn more about Medicaid Self Direction here.
Money Follows the Person
Money follows the person – this Medicaid program works with elderly adults who are in nursing care, and if they are able, helps to transition them back to living, somewhat independently, in their own homes.
Items which are required both for making the transition, and then to the elderly person maintaining their independence, are paid for by the program.
This can be buying standard DME or it can be as much as remodeling parts of a home to make the move possible.
The range of DME allowed is considerably wider than with Medicare, which certainly does not cover home modifications.
If your income is slightly too high for Medicaid eligibility
In some states there’s a program called Spend-Down.
The Spend-Down program helps a person to reduce their income level so that they are eligible for Medicaid, HCBS’s and waivers.
This won’t work if your income and assets are way above the Medicaid eligibility limit, unless you have rather excessive medical expenses.
One method is to allow a person to subtract their medical bills from their income, and if as a result their income level falls below the limit for Medicaid eligibility, the person will qualify for assistance and will be eligible apply to the different HCBS’s and waivers.
You can read all about it in an article on the US NEWS website here.
How to get DME with Medicaid and state waivers and HBSC programs ?
– the doctor, or therapist, has to provide a medical justification letter, stating it is medically necessary
– find a Medicaid-approved DME supplier , and give them the medical justification letter
– the Medicaid-approved supplier fills out a Prior Approval Application form for Medicaid
– the Prior Approval Application is sent to the Medicaid State Office
– if you are unsuccessful you will be contacted and given the reasons as to why, as well as advice on how to make an appeal
– if approved, you will receive the DME
Find the HCBS programs, waivers and 1915 waivers with their eligibility criteria in your state
Step 2 –
Click on you state
Step 3 –
- your state Medicaid Agency marked with a (1), or
- your state Home and Community Based Services, Waivers and 1915 Waivers marked with a (2)
You will then see a page like this example below, with the programs and waivers in your state, and their eligibility criteria.
To find your State Medicaid State Agency
Step 1 –
Click the link to Medicade.gov, look to the section I outlined in red.
Step 2 –
Select your state and click on the button they have marked “GO” – it will take you to your State Medicaid Agency with all their contact info.
State Funding Assistance
Assistive Technology Programs
Assistive Technology Programs are present in each state to improve access to assistive devices in the home, with a primary focus on the elderly and the disabled.
The classification “Assistive Technology” covers equipment which enables users to complete tasks they otherwise couldn’t – it can be anything from kitchen safety equipment through to digital devices.
Pick your state on the map or the drop down menu, and click on “Go to state”
– I chose Florida for this example
State Financial Assistance Programs
In a number of states, you can find non-Medicaid programs which help the elderly to remain living in their homes.
The programs will pay for safety equipment, assistive equipment, and even the cost of remodeling bathrooms, kitchens, wheelchair ramps – the costs are paid for with grants or loans, or a combination of both.
You can find out about these from your local Area Agency on Aging.
To locate your local Area Agency on Aging click here.
You can get rigid and semi-rigid back braces covered by Medicare Part B, if you have a signed prescription from a Medicare-enrolled doctor stating that it is “medically necessary”.
You must get your brace through a Medicare-enrolled “Participating” supplier who accepts “assignment” and you will only have to pay a co-payment of 20%, and your deductible if it applies.
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