Frequently Asked Questions About Insurance Coverage for Custom Orthotics, Shoes and Shoe Modification

Patients often have questions about their insurance coverage for custom orthotics, shoes and shoe modifications. While every plan is slightly different, here are some frequently asked questions and answers, including information from the Canadian Life and Health Insurance Association (CLHIA). The CLHIA produces guidelines that are generally followed by health insurance companies.

Please note: The information provided here is for reference only. All claims are adjudicated in accordance with the terms of your benefit plan. Please defer to your plan and insurance provider for the most accurate information.

Custom Made Orthotics

Does my plan cover custom orthotics?

Will I need a prescription for custom orthotics and where do I get one?

Are custom orthotics manuractured by Ottawa Custom Orthotics eligible as custom orthotics?

As a pedorthist, are you an eligible dispenser of custom orthotics?

What paperwork do I need to submit to my plan administrator for custom orthotics?

Will my insurance plan cover my custom orthotics?

Shoes

Does my plan cover orthopedic shoes?

Will I need a prescription for orthopedic shoes and where do I get one?

Which shoes qualify as orthopedic shoes?

Would dress-shoes be covered under my insurance plan?

Shoe Modification

What is shoe modification?

Does my plan cover shoe modification and does that include the shoe that is being modified?

Custom Made Orthotics

Does my plan cover custom orthotics?

Custom orthotics are covered by many but not all benefit plans. It is best to check with your insurance provider to determine if you plan covers custom orthotics.

Will I need a prescription for custom orthotics and where do I get one?

Yes, you will need a prescription. At Ottawa Custom Orthotics, many of our patients have prescriptions from their family doctor, but there are others who can provide a prescription as well. Your plan will have a list of eligible prescribers. The prescription must set out a medical diagnosis necessitating the supply of custom orthotics.

Are custom orthotics manuractured by Ottawa Custom Orthotics eligible as custom orthotics?

Yes. According to the Canadian Life and Health Insurance Association Inc. (CLHIA), “Custom made orthotics are functional devices made from a cast impression of the patient’s foot and constructed from raw materials to each patient’s specifications. The orthotic is removable from the patient’s footwear.” At Ottawa Custom Orthotics, Leon Kozliner, C Ped (C), hand crafts all of their orthotics on-site in this required manner.

As a pedorthist, are you an eligible dispenser of custom orthotics?

Yes. “Canadian Certified Pedorthist are orthotic and orthopaedic footwear experts. They are one of the few healthcare professionals trained in the assessment of lower limb anatomy and biomechanics.”

What paperwork do I need to submit to my plan administrator for custom orthotics?

According to the CLHIA, “ Insurance companies and benefit plan administrators typically require the following documentation when considering a claim for orthotics:”

  1. “A completed, signed and dated claim form”. The claim form can be obtained from your insurance provider and sometimes from your Human Resources Department.
  2. “A copy of the prescription written by an eligible prescribing practitioner indicating…the patient’s diagnosis necessitating the use of orthotics”. In my practice, the majority of prescriptions are issued by family physicians. Check with your insurance provider for a complete list of eligible prescription providers.
  3. At Ottawa Custom Orthotics, as a dispensing practitioner, we provide the remaining required documentation:
    • A detailed biomechanical examination, which includes a copy of your stance and gain analysis
    • Details of the casting techhique and materials used
    • An official receipt which includes:
      • The name, address and qualification of the orthotics dispenser
      • A detailed description of the type of orthotics
      • A breakdown of charges
      • The date of full payment for the orthotics
      • The dispensing date of the orthotics


 

Will my insurance plan cover my custom orthotics?

If you are not sure about your coverage for orthotics, we can prepare an estimate and supportive documentation. You can submit this with your prescription to your insurance provider.

You will receive a precise quote indicating the amount that would be covered.

Shoes

Does my plan cover orthopedic shoes?

Some benefit plans cover orthopedic shoes. As with custom made orthotics, it is best to check with your insurance provider to determine if your plan covers orthopedic footwear.

 

Will I need a prescription for orthopedic shoes and where do I get one?

If your benefit plan covers shoes, you will need a prescription. Your plan will have a list of eligible prescribers.

Which shoes qualify as orthopedic shoes?

Your plan will describe specific criteria. Typically, plans require most of the following to qualify as an orthopedic shoe:

  1. a removable full-length insole

  2. additional depth built into footwear to accommodate toes

  3. adjustable closures such as laces or velcro

  4. a smooth protective inner lining

  5. a shoe that is shaped to accommodate anatomy of the foot

  6. appropriate stability throughout the shoe

  7. a heel the counter that is firm and stable

  8. an outer sole that is at least the same width as the upper

  9. a sole that is rockered on the toe to promote normal gait

  10. a shoe that can accommodate permanent modification

Some plans also require that the shoe be attached to a brace.

Would dress-shoes be covered under my insurance plan?

Most insurance plans only cover orthopedic footwear only. Check your plan for details.

 

Shoe Modification

What is shoe modification?

Shoe modification is a permanent change to the orthopedic shoe to accommodate or control foot deformities or conditions. It becomes an integral part of the shoe. It is not a removable device.

 

Does my plan cover shoe modification and does that include the shoe that is being modified?

Some plans will cover the cost of shoe modification only and other plans will cover the cost of the shoe as well. As with custom orthotics and shoes, it is best to check specific coverage with your insurance provider.