Does Medicare Pay For Neck Braces ?

by | Beginners Info, Health Care

As our loved ones get older and their health declines, even if it is not serious, the costs of all the different pieces of equipment they need starts to really add up, and you really have to brace yourself for what is coming next … Please excuse me that little pun, but I couldn’t resist. And I hope that you don’t need one for your elderly parent, or loved one, but today’s topic is neck braces.

Does Medicare cover neck braces ? Yes, Medicare Part B typically covers 80% of the cost of “medically necessary” neck braces, or cervical orthoses, under the Durable Medical Equipment Orthotics Benefit, if you have a prescription from a Medicare-approved doctor. If you can’t get coverage under Medicare you may be able to under other state funded programs for the elderly and disabled.

Medicare part B will cover a neck brace if it is “medically necessary” under the Benefit for Orthotics or Braces.

To qualify for a neck brace you must need one of the following–

  • stabilization of the neck because of a weakness or deformity
  • restriction of the movement of the neck due to an injury or disease
  • limitation of movement of the neck during recovery from a surgical procedure

You will need to have a face-to-face appointment with a Medicare-enrolled doctor and to get a signed prescription which certifies that you qualify under one of the above criteria, and as such that a neck brace is “medically necessary”.

What type of neck brace are you allowed ?

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

The difference between the two types of braces –

Custom Fitted Braces –

Even though custom fitted braces may come in kit form, they require fitting by a certified Orthotist, as they may demand an important amount of modification during the fitting process to make a proper fit.

Off-The-Shelf braces –

Off-The-Shelf braces may come as a kit and will require some assembly, but this should only be 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 is from the Medicare Benefits Policy Manual Chapter 15 – Revised 2019 which you can find 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.”

Does Medicare cover back braces ?

To get coverage for a back brace under Medicare Part B, you will again need to get a signed prescription from a Medicare-enrolled doctor, certifying that the back brace is “medically necessary” for you.

You must have a face-to-face appointment with the doctor so that he can make a proper diagnosis.

The passage below is Medicare’s guidelines for back braces, which they call “Spinal Orthosis”.

The doctor will have to check that you comply with one of the criteria before he can sign a prescription for a brace.

“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 other words the back brace must do one of the following to qualify for coverage –

  • restrict movement of the torso to reduce pain
  • promote the healing of the spine or muscles, ligaments after an injury, or after surgery
  • give support to a weak and/or 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.”

Your Medicare-enrolled doctor will tell you which type of back brace you require on your prescription, and you should be able to choose one from different brands at the supplier.

Below are some of the more well-known brands –

  • Aspen
  • Corflex
  • Comfortland
  • Ossur

Your Medicare-enrolled supplier will have the brands he works with, so if you don’t find the brand you want, you may have to seek out a number of Medicare-enrolled suppliers.

Does Medicare cover knee braces ?

Medicare Part B will typically give coverage to knee braces, just so long as you have a prescription from a Medicare-enrolled doctor certifying it is “medically necessary”.

You will have to have a face-to-face appointment with a Medicare-enrolled doctor so that she ,or he, may examine your knee to make sure that your condition is one of those which falls within the Medicare gudielines for coverage, and can be certified as “medically necessary”.

If you want to find out more about knee braces, what the Medicare guidelines are for getting coverage are, which types are covered, and also other sources of coverage or funding for a knee brace, you can read that in my article here.

Does Medicare cover bathroom equipment ?

 Medicare Part B will only cover equipment for use which it considers to be “medically necessary”.

As a result a lot of safety equipment which you may have thought Medicare would cover, is not covered.

The majority of the equipment used in bathroom for safety is not covered, such as –

  • grab bars
  • raised toilet seats 
  • bath lifts
  • bath seats
  • floor to ceiling poles
  • shower chairs
  • bath chairs
  • transfer seats
  • toilet safety frames

Most of the items aren’t covered because they are “not medical in nature” or they are “for comfort”.

Medicare does though consider equipment for those mobility issues as “medically necessary”, and if you have difficulty walking, or standing, you may qualify for coverage of the following items –

  • crutches
  • walkers
  • bedside commodes

There are some items which are a little more difficult to understand, for example if you are bed bound, a patient lift, as it is called by Medicare, is covered, so that you may get into a wheelchair etc.

But if you cannot get into the bathtub, but you can get out of bed, you may not get a bath lift.

The lift to help you out of bed is considered “medically necessary”, so that you are not left stuck in bed, and the bath lift is considered a comfort item which Medicare will not cover.

Patient lifts will though transport and place someone in a bathtub who cannot walk.

Medicare 5 year replacement rule 

DME can be replaced by Medicare part B when they are –

  • worn out from use
  • that have been in your possession throughout their lifetime
  • too far gone be fixed

Two final points –

  • the shortest period to be considered a lifetime for DME is five years
  • the lifetime may vary depending on the type of equipment

Typically, a neck brace which is “worn out” may be replaced every five years, if it has been in the beneficiary’s possession for that whole period.

Knee braces though have a lifetime of 1 1/2 to 2 years.

Medicare Part B will pay to repair non-functioning DME which haven’t reached the end of their lifetime, but will not pay more than the cost of an equivalent replacement.

If you are replacing an item, you have to go through the whole Medicare procedure with the doctor and supplier all over again.

How does Medicare decide on which equipment it will cover ?

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

Durable Medical Equipment must

  • tolerate constant use over a sustained period of time – durable
  • be primarily medical in nature – not for comfort
  • useful only to a person who is ill
  • principally for use in the home
  • it has have a minimum lifetime of at least 3 years

How do you get coverage from Medicare Part B for DME ?

For you to get covered by Medicare Part B for Durable Medical Equipment for “use in the home” –

  • you are going to have to be enrolled in Medicare Part B
  • you must have a Medicare-enrolled doctor to give you a signed prescription which certifies that the equipment is a medical necessity
  • the equipment must come 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

Okay, you have your prescription, what’s next ?

It’s time to choose your DME.

Your doctor will doubtless be able to advise you on some of this –

  • you need to locate a Medicare-enrolled supplier who has your type of DME
  • you only want to deal with a supplier who is a Medicare-enrolled “participating supplier who accepts “assignment’ – doing this you will have the lowest possible costs
  • the models of DME Medicare covers are rather basic, although if you are willing to pay, you may sometimes be able to upgrade to a model you prefer
  • make your choice from what is available
  • fill out any compulsory paperwork for Medicare with the supplier

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.

Remember to always go through Medicare-enrolled supplier who is a Medicare-enrolled “Participating” supplier who accepts “assignment”,so that you don’t end up paying money that you shouldn’t have to.

 

Medicare both rents and purchases DME – If your equipment is rented by Medicare from the supplier, you will just pay a 20% co-payment of the monthly rental each month, and at the outset, if it applies, your deductible.

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

Are neck braces covered by Medicare Advantage plans ?

Medicare Advantage plans will, by law, cover, at the least, everything covered by Medicare  Parts A and B, and sometimes, depending on the plan, some extras.

So, yes, neck braces are covered by Medicare Advantage plans, and the same Medicare guidelines for use in the home apply as for Medicare Part B.

You will need to contact you plan provider and find out which doctors and suppliers to use, if you don’t already know.

Don’t go outside your provider’s network, as you will doubtless lose coverage and have to pay for the brace yourself.

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, go 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.

One-on-one advice on Medicare that’s free !

State Health Insurance Assistance Programs – SHIP – give free counseling on Medicare for those in need of advice.

SHIP also gives free advice on Medicare Advantage, Medigap and Medicaid benefits.

The majority of the time SHIP counseling is done over the phone, but occasionally some of the programs do offer face-to-face appointments as well.

For your local Medicare SHIP click 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 neck and other braces ?

   Medicaid has a very different funding structure from Medicare, as its programs gain funding both federally and by each individual state.

Concretely, this results in each individual state having quite a lot of wiggle room in what it does with its Medicaid programs, just so long as it keeps within the main Medicaid guidelines.

It is normal for Medicaid to permit a state to waive some of its eligibility requirements for certain programs, so that they may be able to give health care to a group people who might otherwise not receive any.

This permission to ignore some of the normal eligibility requirements is known as a Waiver, and each waiver can have very specific eligibility requirements of its own, targeting specific groups of the population, and often with a limited numbers of places.

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

Care for the elderly in the home – Medicaid and state programs

Programs providing care within the home, and which are principally for the elderly, very low income families and the disabled are called “Home and Community Based Services” (HCBS), “Waivers” or “1915 Waivers”.

HCBS programs, waivers, and 1915 waivers exist to help the participants to maintain their independence, and will all help to pay for “home medical equipment”, very often covering the whole cost.

See if you are eligible for an HCBS program or waiver, by contacting your State Medicaid Agency here.

You can also find out more at your local Area Agencies on Aging.

Use the link below to find out more on HCBS programs or waivers –

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

 

A “home” for Medicaid is any of the following –

  • their own home
  • their family home
  • a group home
  • an assisted living facility
  • a custodial care facility

 

Programs and waivers are most likely cover more varied range DME for “in home use”

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

“Consumer Direction”or “Self Direction” is essentially a self-managed program model, where the participant makes a lot of the decisions about how their program budget is spent.

To help guide them, they will be appointed a financial advisor.

So long as the participant’s budget has enough money in it, equipment essential to them participating in the program, or waiver, is covered.  

Learn more about Medicaid Self Direction here.

Money Follows the Person

This is a federal Medicaid program which was set up help elderly adults living in nursing homes to move back into their own homes. 

The Medicaid program assists the states with funding to set up Money Follows The Person Programs.

The states can use HCBS waivers which already exist, or they can establish whole new programs, to help the elderly to make the transition back to their homes.

The programs will give the money required for making the transition, and for the elderly persons to maintain their independence. This can be buying standard DME or remodeling parts of a home.

Is your income too high for Medicaid eligibility ?

Spend-Down.

Spend-Down is a program which helps people, whose income level may otherwise be too high for Medicaid eligibility, to reduce it that income level, and to qualify for Medicaid based programs and waivers.

One avenue Spend-Down offers, is to allow a person to subtract their medical bills from their income, and to reconsider the new total as their income level. If it falls below the  limit for Medicaid eligibility, the person will be allowed to 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 ? 

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 –

Select your state on 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 in each state are funded by a national grant to improve access to assistive devices in the home.

The programs concentrate principally on working with the elderly and the disabled.

“Assistive Technology” covers equipment which makes it possible for users to accomplish tasks they otherwise cannot – it can be anything from special shoe horns or adapted stove knobs through to digital safety equipment.

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 which help the elderly to remain living as independently as possible in their own homes.

With grants and loans, or a combination of both, the programs will pay for safety equipment, assistive equipment, and sometimes for remodeling homes.

The programs principally focus on the elderly and the disabled.

Your local Area Agency on Aging should be able to help you find out if you have one in your state.

Summary

You can get 80% coverage for rigid and semi-rigid neck braces with Medicare Part B, if you have a signed prescription from a Medicare-enrolled doctor stating that it is “medically necessary“. 

The braces can be “Custom Fitted” or “Off-The-Shelf” and your doctor will tell you what type you need, if you qualify for coverage.

Only 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.

If you don’t qualify under Medicare you may be able to qualify with Medicaid. If you income is a little too high, don’t forget to check and see if your state has Spend-Down, and see if you qualify.

You may also be eligible for different state funded programs which help the elderly to maintain their independence, along with Medicaid HCBS programs, waivers and 1915 waivers.

If you are a little overwhelmed by tracking everything down, I would either call your state SHIP program for a chat, or just find out where your local Area Agency on Aging is, and go and see if they can give you help with finding resources.

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 pay for neck braces ?
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Yes, Medicare Part B typically covers "medically necessary" neck braces, or cervical orthoses, under the Durable Medical Equipment Orthotics Benefit if you have a prescription from a Medicare-approved doctor. If you can't get coverage under Medicare you may be able to under other state funded programs for the elderly and disabled.
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