Extended Health Plans.
Questions
to ask your insurance provider.
This is a general guide to extended
health plans that are often tailored to individual companies.
Call your insurance provider to confirm your coverage!
1) Do I need a Prescription?: In
most cases you will require a medical doctor's prescription (Rx) to have
orthotics covered by your insurance plan. A prescription from your family doctor or clinic is
acceptable and most will also accept a podiatrist or chiropodist, but
will not accept a prescription issued by a chiropractor,
physiotherapist, nurse practitioner, etc. Most plans also require a
diagnosis (Dx) (e.g. custom orthotics for heel spurs). A new
prescription is usually required each time orthotics are made, but some
insurance companies keep the prescription on file for 3 years
and in rare cases forever. A prescription must be filled within a
certain length of time, usually one year.
2) How much am I covered for?: Plans
are all different. Some cover a percentage of the total cost, for
example 80% up to a certain amount. Some have a maximum dollar limit such as $300 per pair. Some plans allow for a maximum amount for all your extended benefits per year.
3) How often can I get orthotics?: Most
plans
cover 1 pair of custom orthotics a year or once per calendar year. However, some
plans only cover a pair every 2 years or more. Some cover more than
one pair per year. Some
allow a dollar maximum amount per year regardless of the number of
pairs.
4) Am I covered for shoes?: Rarely are off the shelf shoes covered. In specialty footwear, there are three categories. An orthopaedic shoe
is an extra depth, multiple width shoe that usually includes a shaped
insole. Generally these shoes are made to work well with custom
orthotics, but are not modified in any way so are not considered custom
shoes. A custom modified shoe is an orthopaedic shoe that has been modified for you (e.g. a lift for a leg length correction). A custom made shoe involves
making a full cast of the feet from which an actual shoe last is made
and the shoes made to accommodate any foot deformities or high pressure
areas. This process is very expensive, $600 & up, and is usually
only approved if prescribed by an orthopaedic surgeon.
5) Once I have a prescription, who can assess me for orthotics?
Most insurance companies require a biomechanical
assessment & gait analysis to be performed by a Pedorthist,
Podiatrist, Chiropodist, or Orthotist and a copy of the report be included with
your claim submission. Some insurance providers require the prescribing professional cannot perform the assessment and dispense the orthotic.
6) What other information must I submit with my claim?
If a prescription is required, the original copy must be submitted (make copies!). Also, the qualifications of the person doing the
assessment and a description of the casting technique and the materials
used in constructing the orthotics is often required. If the provider
uses an outside lab to make the orthotics, a copy of the lab bill is
submitted. In all cases, an invoice for the orthotics must be
submitted with proof of payment.
From Manulife Financial's brochure...
Custom made orthhotics are prescribed by specific healthcare professionals, which include physicians, podiatrists and chiropodists. They will diagnose whether or not an orthotic would be beneficial to your situation.
Many suppliers offer orthotics but podiatrists, chiropodists, pedorthists and certified orthotists are recognized as foot care specialists and are trained specifically to assess, design, manufacture and fit foot orthotics.
The prescribers and providers listed above are licensed and governed by either a provincial or national body, and are subject to standards of practice. This, along with each body's Code of Ethics, helps ensure their accountability and your protection.