Does Medicare Cover Elbow Braces ?

by | Beginners Info, Health Care

Does Medicare cover elbow braces ? Yes, Medicare Part B typically covers medically necessary elbow braces if they have been prescribed by a Medicare-approved doctor. If you can’t get coverage under Medicare you may be able to with Medicaid, an HCBS waiver, or with state funded programs for the elderly and disabled.

To get your elbow brace covered under Medicare Part B you will need to have a face-to-face appointment with a Medicare-enrolled doctor, who will have to certify that it is “medically necessary” for you to have one, and that you will benefit from the brace, for which the doctor will give you a signed prescription.  

To qualify you must need an elbow brace for one of the following reasons –

  • to stabilize the elbow because of a weakness or deformity
  • to restrict movement of the elbow joint because of an injury or disease
  • to facilitate healing following a surgical procedure 

If you satisfy one of the above conditions the doctor will give you a signed prescription, and you can take this to a Medicare enrolled-supplier to choose your model of brace.

What type of elbow brace are you allowed ?

You are allowed to choose from, either Custom Fitted, or Off-The-Shelf elbow braces with coverage under Medicare part B.

The difference between the two types of braces –

Custom Fitted Braces –

Custom fitted braces require fitting by a certified Orthotist, as they may demand an important amount of modification during the fitting process to make the best possible fit.

Off-The-Shelf braces –

Off-The-Shelf braces should only require minimal adjustments, which the beneficiary can easily do themselves.

They should not require the help of a certified Orthotist for the best possible fit.

The passage below explains the rules for the type of braces allowed – 

Medicare Benefits Policy Manual Chapter 15 – Revised 2019 you can find it  here.

130 – Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes (Rev. 1, 10-01-03) B3-2133, A3-3110.5, HO-228.5, AB-01-06 dated 1/18/01

“These appliances are covered under Part B when furnished incident to physicians’ services or on a physician’s order.

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. Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of a brace.”

 

“Adjustments, repairs and replacements are covered even when the item had been in use before the user enrolled in Part B of the program so long as the device continues to be medically required.”

There are many elbow braces to choose from, and of course your Medicare-enrolled doctor will advise you on what type you need, and on the different brands.

Does Medicare cover back braces ?

Yes, Medicare Part B typically covers 80% of the cost of back braces, if you have a prescription from a Medicare-enrolled doctor certifying that you qualify under Medicare’s criteria, and the brace is “medically necessary”.

You will have to have a face-to-face meeting with the Medicare-enrolled doctor to get the prescription, so that they can actually see that you really need a brace, and if so, what type. 

I have an article about Medicare and the coverage of back braces, with much more specific information about what qualifies for coverage, types of back braces and popular brands of braces which Medicare covers.

If you don’t qualify for Medicare coverage I outline other sources for funding for a back brace for elderly adults. You can find that article here. 

Does Medicare cover knee braces ?

Knee braces are typically covered up to 80% by Medicare Part B, so long as you have had a face-to-face appointment with a Medicare-enrolled doctor, and were given a signed prescription stating that the brace was medically necessary.

I have a whole article on Medicare Part B and knee braces, you will be able to see what types of braces are covered, and under what conditions. You can find that article here.

Does Medicare cover “walking boot” ?

Medicare Part B does also typically cover “walking boots”, or ankle/orthosis as they are known technically, if they have been prescribed by a Medicare-enrolled doctor certifying that they are “medically necessary”

Medicare Part B, of course, will only cover the “walking boot” for certain conditions, which is why you will be obliged to have a face-to-face appointment with the prescribing doctor to establish that you qualify.

If you wish to know more about the conditions for qualification and the types of boot that Medicare will cover, you can read my article on Medicare and “walking boots”.

I also cover the different sources of funding which are available other than Medicare, such as Medicaid, Assistive Technology Projects and other state financial assistance funds which exist to help the elderly. You can read that article here.

Will Medicare cover your bathroom safety equipment ?

Bathroom safety equipment, in general, does not get coverage from Medicare Part B, for the simple reason that most of it is not considered medical in nature, and so cannot be “medically necessary”, and so can’t qualify for coverage.

Everything which is covered by Medicare must be “medically necessary”, which differs from other state programs, which work to help the elderly maintain their independence in their homes, by creating a safe environment for them.

Medicare does cover the three following items which can be used in the bathroom to help with safety –

  • crutches
  • walkers
  • bedside commodes

Don’t despair though, as I have written an article on bathroom equipment, Medicare, and the types of funding, grants and insurance, which will give coverage. If you are interested in that you should take a look at my article here.

If you are starting out as a caregiver, and you want bathroom safety tips to help an elderly person with bathing, I have an article with over 50 tips that I have learned in my 10+ years as a caregiver.

It covers a whole range of safety issues, about setting up the bathroom, hazards to look out for, safety products, and a few tips on how to go about it. You can find that here.

What types of equipment does Original Medicare Part B cover for use in the home ?

The equipment covered by Medicare Part B “for use in the home” is called “Durable Medical Equipment”, or DME.

Durable Medical Equipment must –

  • be able to withstand constant use over a sustained period of time – durable
  • be medical in nature
  • only useful to a person who is ill
  • be principally for use in the home
  • it has have a minimum lifetime of at least 3 years

How does a person get coverage from Medicare Part B for DME ?

To get coverage 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

Once you have a prescription what is the procedure ?

It’s time to go choose your DME –

  • go find some Medicare-enrolled DME suppliers in your area who have elbow braces
  • make sure the supplier that you choose a Medicare-enrolled “participating supplier who accepts “assignment” – this way you don’t pay any extra
  • select your elbow brace that you have been prescribed from the available choices
  • if you don’t like the basic models of elbow brace which are covered by Medicare, you may have the opportunity on some models to upgrade to a better model, if you pay the difference yourself
  • do all the paperwork for the elbow brace in compliance with Medicare for the supplier

Medicare part B covers 80% of the Medicare-approved price for the elbow brace if you used a Medicare-enrolled supplier with a signed prescription from a Medicare-enrolled doctor certifying that the brace is “medically necessary”.

If you used a Medicare-enrolled “participating” supplier who accepts “assignment”, you just have to pay your Medicare 20% co-payment of the Medicare-approved price for the elbow brace, and your deductible if it applies.

Do get your elbow brace through Medicare-enrolled supplier who is a Medicare-enrolled “Participating” supplier who accepts “assignment”, if you don’t you can end up paying extra for the brace.

 

Medicare will either rent or purchase DME – for the majority of equipment Medicare will rent from the supplier.

On rented items, you pay (monthly) a 20% co-payment of the Medicare-approved monthly rental price, 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 have to give the same coverage as Original Medicare Parts A and B – they are private providers who are contracted by Medicare to provide all the Medicare services with the same qualification rules as Medicare.

Whether or not the plans give more coverage than Medicare will depend on supplements they offer, but they must all cover elbow braces under the same conditions as Medicare Parts A and B.

The Advantage plan will though, use their own suppliers and doctors, and you will need to contact you plan provider about this.

If you go outside their 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 

Air-Fluidized Bed
Alternating Pressure Pads and Mattresses
Audible/visible Signal Pacemaker Monitor
Pressure reducing beds, mattresses, and mattress overlays used to prevent bed sores
Bead Bed
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)
Commode chairs
Continuous passive motion (CPM) machines
Continuous Positive Pressure Airway Devices, Accessories and Therapy
Crutches
Cushion Lift Power Seat
Defibrillators
Diabetic Strips
Digital Electronic Pacemaker
Electric Hospital beds
Gel Flotation Pads and Mattresses
Glucose Control Solutions
Heat Lamps
Hospital beds
Hydraulic Lift
Infusion pumps and supplies (when necessary to administer certain drugs)
IPPB Machines
Iron Lung
Lymphedema Pumps
Manual wheelchairs and power mobility devices (power wheelchairs or scooters needed for use inside the home)
Mattress
Medical Oxygen
Mobile Geriatric Chair
Motorized Wheelchairs
Muscle Stimulators
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)
Oxygen Tents
Patient Lifts
Percussors
Postural Drainage Boards
Quad-Canes
Respirators
Rolling Chairs
Safety Roller
Seat Lift
Self-Contained Pacemaker Monitor
Sleep apnea and Continuous Positive Airway Pressure (CPAP) devices and accessories
Sitz Bath
Steam Packs
Suction pumps
Traction equipment
Ultraviolet Cabinet
Urinals (autoclavable hospital type)
Vaporizers
Ventilators
Walkers
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
Urological supplies
Therapeutic shoes or inserts for people with diabetes who have severe diabetic foot disease.

Do you need free help with understanding Medicare ?

State Health Insurance Assistance Programs – SHIP 

SHIP counselors  give free advice and help to anyone withMedicare, Medicare Advantage, Medigap and Medicaid benefits.

Mostly it’s a phone service, but there are programs that may offer in-person appointments as well.

If you want to find your local Medicare SHIP click here.

All you have to do is to give them a call !

How to contact a SHIP counselor in your state, step by step

Step 1 –

You will come to this page –

Step 2 –

Click on a button to find your state – both buttons lead to the same menu

Step 3 –

From the list select and click on your state

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 elbow braces and other DME ?

 

Medicaid is funded both federally and by each individual state.

The individual states can have quite a lot of variety in the programs they provide with Medicaid, so long as they stick within the basic guidelines, and it is this which means that it offers, in many cases, far more than Medicare in terms of equipment for use in the home.

Medicaid will often allow a state to waive eligibility requirements for certain programs, so that a state may target a particular demographic with its health care.

The programs on which this is done are known as Waivers, and each different waiver can have its own set of peculiarities to help a certain group of people.

The result is literally hundreds of different waivers, all with different eligibility, and all across the US.

Care in the home – Medicaid and state programs

 

Programs which are principally for low income families, the disabled and the elderly, which work to provide health care services in the home the community are called “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.

These programs have been designed to help the participants maintain their independence at home.

To facilitate this work these HCBS programs, waivers and 1915 waivers will cover part, or all, of the cost of “home medical equipment” required by participants.

To find out if you are eligible for an HCBS program, or waiver, contact your State Medicaid Agency here.

Your local Area Agencies on Aging should also be able to help you find out about waivers in your state, and the eligibility criteria.

If you wish to learn more about HCBS programs or waivers in general, follow the link below –

https://www.medicaid.gov/medicaid/hcbs/authorities/index.html

 

Medicaid uses “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” 

These are management models for program budgets, where the participants, aided by a financial advisor, are largely in charge of the spending of their allocated resources.

The participant is given a budget with which to maintain their independence in their own home.

Items which are vital to the participant continued independence, as long as the budget covers it, are usually allowed.

The range of items to be considered as Durable Medical Equipment is considerably more flexible than that with Medicare.

Learn more about Medicaid Self Direction here.

Money Follows the Person

This is a federal Medicaid program which was designed to help elderly adults to leave nursing homes and to return to live independently in their own homes.

The Medicaid program will help states with the funding to set up their own Money Follows The Person programs – the individual states may use existing waivers already running, or they can establish entirely new programs.

A program’s participants will be assessed, and the necessary resources and materials will be provided, so that the transition from the nursing home to their own home can be made.

The programs may give money for a whole range of things – better lighting, safety equipment, security, medical equipment, or larger investments in remodeling bathrooms and kitchens where necessary.

If your income is slightly too high for Medicaid eligibility

Spend-Down Programs

Unfortunately not present in every state, the Spend-Down program will help a person to reduce their income level so that they may become eligible for Medicaid, HCBS’s and waivers.

One approach is to allow a person to deduct their medical expenses from their income, and to consider that as their income level.

If it falls below the limit for Medicaid eligibility, the person may then be able to qualify for different HCBS’s and waivers.

You can find out much more about it in this article on the US NEWS website here.

How to get DME with Medicaid and state waivers and HBSC programs ? 

Step 1

– the doctor, or therapist, has to provide a medical justification letter, stating it is medically necessary

Step 2

–  find a Medicaid-approved DME supplier , and give them the medical justification letter

Step 3

– the Medicaid-approved supplier fills out a Prior Approval Application form for Medicaid

Step 4

– the Prior Approval Application is sent to the Medicaid State Office

Step 5

– 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

Step 6

– if approved, you will receive the DME

Find the HCBS programs, waivers and 1915 waivers with their eligibility criteria in your state

To find what is on offer in your state click here and follow the steps outlined below.

Step 1 –

Pick your state from the map.

Step 2

Click on you state 

Step 3 –

Choose –

  • 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

If you just want to talk to, or to email someone, contact you state Medicaid Agency here.

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

Every state receives an Assistive Technology Program grant to improve access to assistive devices in the home – they are principally focused on the elderly and the disabled.

“Assistive Technology” is equipment which assists users in completing tasks they have trouble with. The equipment can be anything from a special dressing aid to digital communication devices.

To find out what projects your state runs click here

Step 1/

Pick your state on the map or the drop down menu, and click on “Go to state”

– I chose Florida for this example

Step 2/

Click on the link “Program Title” – for my example I outlined it in red.

Step 3/

The AT Program state website will come up, and you can sign up, or use their contact info .

State Financial Assistance Programs

State Financial Assistance Programs are found in some, but not all states.

These are non-Medicaid programs focused on helping the elderly to remain living in their homes.

Equipment which is needed for the elderly to participate in the programs, and even remodeling bathrooms, kitchens, or building wheelchair ramps are paid for with grants or loans, or a combination of both.

I would suggest you go ask about these programs at your local Area Agency on Aging.

    Summary

    If you have a signed prescription from a Medicare-enrolled doctor certifying that an elbow brace is “medically necessary”, you can typically get rigid and semi-rigid elbow braces covered 80% by Medicare Part B.

    You should always get your elbow brace through a Medicare-enrolled “Participating” supplier who accepts “assignment”, so that you only have to pay a co-payment of 20% of the Medicare-approved price, and your deductible should it apply.

    If by any chance you don’t qualify for Medicare coverage, take a look at Medicaid, HCBS programs, waivers, 1915 waivers and State Financial Assistance Programs for which you may be eligible.

    I’m Gareth and I’m the owner of Looking After Mom and Dad.com

    I have been a caregiver for over 10 yrs and share all my tips here.

    Gareth Williams

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    Does Medicare cover elbow braces ?
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    Yes, Medicare Part B typically covers medically necessary elbow braces if they have been prescribed by a Medicare-approved doctor. If you can’t get coverage under Medicare you may be able to with Medicaid, an HCBS waiver, or with state funded programs for the elderly and disabled.
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