Insurance Issues

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. Because there are many different providers of orthotics and recent changes in policies by the insurance companies, we would encourage you to submit a written estimate to your insurance provider for approval prior to starting the process.

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 specific diagnosis (Dx) (e.g. custom orthotics for plantar fasciitis). 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 speciality 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 this report be included with your claim submission. Note other medical professionals like chiropractors and physiotherapists are usually not recognized. Some insurance providers require that the prescribing professional cannot also 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 usually 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 orthotics 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.