Does Medicare Cover Knee Braces ?

by | Beginners Info, Health Care

Over the last 18 months since my mom had her hip replacement surgery, her right knee has become more and more troublesome. As her caregiver, and as “he who investigates for solutions to problems”, I have been looking into knee replacement surgery  and also different types of knee braces for osteoarthritis, and how these will be paid for. 

Does Medicare cover knee braces ? Yes, Medicare Part B typically covers knee braces which have been prescribed as “medically necessary” by a Medicare-approved doctor. If you can’t get coverage under Medicare you may be able to with Medicaid under other state Non Medicaid programs for the elderly and disabled.

To get a brace you will have to have an in-person appointment with a Medicare-enrolled doctor so that they can make a diagnosis, and see if you are qualified under the Medicare criteria.

Medicare Part gives coverage to knee braces as Durable Medical Equipment under the Orthotics or Braces Benefit.

Medicare says a knee brace is “medically necessary” when –

  • a person is able to walk
  • a knee requires stabilization because of weakness or deformity
  • you have had a recent injury to the knee
  • you recently had a knee surgery such as a knee joint replacement

    If you qualify the doctor will give you a prescription certifying that your knee brace is “medically necessary”.

    The doctor will doubtless tell you what type of brace you will need.

    The following text from Medicare outlines the job braces must be able to do, and that they can be either rigid, or semi-rigid.

    Medicare Benefits Policy Manual Chapter 15 – Revised 2019  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.

    What type of knee brace are you allowed ?

    Medicare approves four types of knee braces

    Medicare coverage includes four types of knee orthotics.

    Devices must help manage stability or give pain relief and allow the patient to carry out daily functions.

    Functional  these braces are worn to give support to knees which have been injured in the past. A functional brace stabilizes the joint and control the movement to prevent any further traumas to the knee.

    Functional braces may be used after surgeries to give support to the knee.

    Rehabilitative or Postoperative – these braces, while allowing the joint to move, will protect ligaments and tendons after surgery. The braces do this by limiting potentially harmful movements during the rehabilitation.

    These rehabilitative braces can also be used to prevent a recurring injury.

    Unloader or Off-loader – take the stress off the knee and are used very often to reduce pain from osteoarthritis.

    Unloader braces take pressure off the sides of the knee by limiting the side ways movement , and by putting the pressure on the thigh in order to unload the stress from the joint

    Prophylactic – made for the prevention of knee ligament injuries, in particular the MCL ligament, these are often used by athletes and footballers. They are also worn to prevent further injury to the knee and MCL ligaments by athletes at risk.

    Custom Fitted and Off-The-Shelf

    Medicare Part B allows both Custom Fitted and Off-the-Shelf knee braces.

    Custom Fitted braces

    Custom fitted braces require fitting by a certified Orthotist, as they can require a significant amount of alteration during the fitting to make them fit correctly.

    Off-The-Shelf braces

    These may be supplied as a kit, but that should require only a minimal adjustment for you to fit them properly and do not require the help of a certified Orthotist for the best possible fit.

    Does Medicare cover back braces ?

    To get coverage for a back brace you will need a signed prescription from a Medicare-enrolled doctor, stating that a back brace is “medically necessary”, and as with all the other braces you will need a face-to-face appointment with the doctor.

    Medicare has guidelines about when coverage may be issued to a patient for a back brace.

    The following text is from the 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.”

    What type of back braces does Medicare cover ?

    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.”

    Your Medicare-enrolled doctor will advise you on which type of brace you need.

    Some popular brands are –

    • Aspen
    • Corflex
    • Comfortland
    • Ossur

    You will get your brace from a Medicare-enrolled supplier who may only work with particular brands, so you may have to check out a number of suppliers.

    How does Medicare decide on which equipment it will cover ?

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

    For something 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 ?

    For Medicare Part B to cover your Durable Medical Equipment for “use in the home” –

    • you need to be enrolled in Medicare Part B
    • a Medicare-enrolled doctor has to give you a signed prescription certifying that your equipment is “medically necessary”
    •  arrange the DME 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 signed prescription what’s next ? ?

    As soon you have your prescription –

    • you can visit a Medicare-enrolled DME supplier who has knee braces
    • only get the knee brace from a Medicare-enrolled “participating supplier who accepts “assignment’ – this avoids paying any extra
    • Medicare Part B only covers the more basic models of each type of DME, so if you want an upgrade on the knee brace you will have to pay for this yourself, and it is not always possible
    • select your knee brace from the available choices
    • make sure you have done all the paperwork with the supplier so that you comply with all Medicare’s regulations – the supplier should advise you on all of this

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

    If you got the knee brace from a Medicare-enrolled “participating” supplier who accepts “assignment”, you’ll pay your Medicare 20% co-payment of the Medicare-approved price, and your deductible if it applies.

    You must always get your DME through a Medicare-enrolled supplier who is a Medicare-enrolled “Participating” supplier who accepts “assignment”, if you don’t you risk paying more than you need to.

     

    Medicare both rents and buys DME –

    If your knee brace is rented, you will pay a monthly 20% co-payment of the rental, and if it applies your deductible at the beginning.

    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 cover at a minimum everything offered by Medicare and sometimes, depending on the plan a few extras.

    In this case, as knee braces are covered by Original Medicare, so they are covered by Medicare Advantage plans.

    You will need to contact you plan provider to find out about their network of doctors and suppliers. 

    If you use doctors or suppliers outside of your plans 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.

    Would you like free help understanding Medicare ?

    State Health Insurance Assistance Programs –

    SHIP – give free guidance and advice on Medicare, as well as help with Medicare Advantage, Medigap and Medicaid benefits.

    In general SHIP counseling is over the phone, but sometimes it can be also face-to-face also.

    You can find your Medicare SHIP  here

    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 back braces and other DME ?

    Medicaid programs in each state are funded both federally, and by the individual state itself.

    Consequently, each individual state, so long as it follows the Medicaid guidelines, has quite a lot of leeway in what it does on its Medicaid programs.

    Medicaid will often let a state waive particular eligibility requirements for some of their programs, so that the state may be able to give health care to a certain demographic, which might otherwise be neglected.

    When this occurs it’s known as a waiver.

     A waiver can have its own specific eligibility requirements, and often a limited number places for participants.

    There are literally hundreds of waivers, all with different eligibility criteria, across the US.

    Care in the home – Medicaid and state programs

    “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”

    These are programs which have been established for low income families, the disabled and the elderly.

    The programs provide the participants with health care services in the home, so as they may be able to remain in their homes living independently.

    To help the elderly participants to maintain their independence, these programs and waivers, will all help purchase “home medical equipment”, and very often they pay for it all.

    You can find out if you are eligible for an HCBS program, or waiver, by contacting your State Medicaid Agency here.

    If you prefer you can just visit your local Area Agency on Aging.

    The link below will take you to more information about HCBS programs or waivers –

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

     

    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 with greater possibilities of flexibility with DME for “use in the home”

    HCBS programs and waivers working with “Consumer Direction”or “Self Direction” 

    These are models of program budget management where the participant self-manages the budget they have been allocated.

    The participant is also appointed a financial advisor to assist them. 

    As the goal of the programs is to help the participants to remain living independently in their homes, if they require medical equipment to do so, as long as the budget covers it, they may often be able to get it.

    Learn more about Medicaid Self Direction here.

    The Medicaid Program “Money Follows the Person”

    This a federal Medicaid program which works with elderly adults who are in nursing homes, and if they are able, helps them to return to their own homes.

    Medicaid makes funding available to the different states to set up their own Money Follows The Person programs.

    The states may use existing programs and waivers to help the elderly, or to establish entirely new Money Follows The Person programs.

    The participants are assessed, and the equipment and items required for the move are paid for by the program.

    Remodeling of the homes, the building of wheelchair ramps, improvements in lighting, and the purchase of safety equipment are all possible.

    If your income is slightly too high for Medicaid eligibility

    Spend-Down 

    Unfortunately not present in every state, Spend-Down is a program which helps people get access to Medicaid if their income is too high.

    One frequently used approach, is to deduct all of a person’s medical expenses form their income to try to bring it down to a level where they will qualify, and can then apply for Medicaid benefits in their state.

    There is a comprehensive article about it 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.

    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

    Assistive Technology Programs are funded by a national grant to expand access to assistive devices in the home, principally for the elderly and the disabled.

    “Assistive Technology” is any type of equipment which assists users in completing tasks they otherwise can’t complete, or do so with a lot of difficulty – it can be anything from kitchen safety equipment through to digital hearing devices for the television.

    To find out what programs 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 non-Medicaid programs run by individual states which work to help the elderly to remain living in their own homes.

    Programs will give grants or loans, or sometimes a combination of both, to help pay for safety, medical, or assistive equipment, as well as the costs of remodeling bathrooms, kitchens, wheelchair ramps if needed.

    The principal focus of such programs are the elderly and the disabled.

    You can get more information about programs in your state from your local Area Agency on Aging.

      Summary

      Rigid and semi-rigid knee braces are covered by Medicare Part B, when you have a signed prescription from a Medicare-enrolled doctor stating that it is “medically necessary” according to the Medicare guidelines.

      You should always get your knee brace, or any other DME for that matter, from a Medicare-enrolled “Participating” supplier who accepts “assignment” so that you will only pay your co-payment of 20% of the Medicare-approved price, and if it applies, your deductible.

      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

      Recent Content

      Summary
      Article Name
      Does Medicare cover knee braces ?
      Description
      Yes, Medicare Part B typically covers knee braces which have been prescribed as "medically necessary" by a Medicare-approved doctor. If you can't get coverage under Medicare you may be able to with Medicaid under other state Non Medicaid programs for the elderly and disabled.
      Author
      Publisher Name
      Lookingaftermomandad.com