Medicaid Benefits: Prosthetic and Orthotic Devices
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2018
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limits on Services | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 45 No - 1 NR - 5 | 2018 data limited to CN | Yes - 13 | Yes - 30 | Included in "Limits on Services" for 2018 | Not included in 2018 survey |
| Alabama | Yes | CN | $0.65-3.90 | on prior authorization | - | - |
| Alaska | Yes | CN | $3 | Must be prior authorized | - | - |
| Arizona | Yes | CN | No | Covered devices do not include hearing aids, cochlear implants, bone anchored hearing aids, microprocessors for controlled joints for the lower limbs, penile implants, and vacuum devices | - | - |
| Arkansas | Yes | CN | NR | NR | - | - |
| California | Yes | CN | No | Limited to services and items to restore function. | - | - |
| Colorado | Yes | CN | $1 per visit | No | - | - |
| Connecticut | Yes | CN | No | Diabetic or orthotic shoes limited to 2 pairs a year; combined limit. | - | - |
| Delaware | Yes | CN | No | medically necessary | - | - |
| District of Columbia | Yes | CN | No | Some supplies and equipment require PA | - | - |
| Florida | Yes | CN | No | 1 per lifetime | - | - |
| Georgia | Yes | CN | $3 copay | Orthopedic shoes are not covered. | - | - |
| Hawaii | Yes | CN | No | No | - | - |
| Idaho | Yes | CN | No | No | - | - |
| Illinois | NR | NR | NR | NR | - | - |
| Indiana | Yes | CN | No | Prior authorization for specified services, limitations vary by specific device. | - | - |
| Iowa | NR | NR | NR | NR | - | - |
| Kansas | Yes | CN | $3.00 per claim | No | - | - |
| Kentucky | Yes | CN | $4 | NR | - | - |
| Louisiana | Yes | CN | No | No | - | - |
| Maine | Yes | CN | $.50 to $3/day depending on payment amount, up to $30/month | No | - | - |
| Maryland | Yes | CN | NR | some services are pre-authorized | - | - |
| Massachusetts | Yes | CN | No | No | - | - |
| Michigan | Yes | CN | No | Some items require PA | - | - |
| Minnesota | Yes | CN | No | No | - | - |
| Mississippi | No | - | - | |||
| Missouri | Yes | CN | NR | NR | - | - |
| Montana | Yes | CN | Income at or below 100% FPL - $4 per visit; above FPL - 10% of payment amount | Medicare criteria followed | - | - |
| Nebraska | Yes | CN | $3 per specified equipment, prosthetic, orthotic or other supply | Back-up equipment orders are not reimbursable | - | - |
| Nevada | NR | NR | NR | NR | - | - |
| New Hampshire | Yes | CN | No | NR | - | - |
| New Jersey | Yes | CN | No | quantity limits, prior authorization | - | - |
| New Mexico | Yes | CN | No | No | - | - |
| New York | NR | NR | NR | NR | - | - |
| North Carolina | Yes | CN | No | quantity limits, life expectancies, age limits | - | - |
| North Dakota | Yes | CN | No | Prior approval required for services based on policy requirements. | - | - |
| Ohio | Yes | CN | No | multiple frequency limits are used | - | - |
| Oklahoma | Yes | CN | $4 copay per claim | Limited coverage for prosthetics with prior authorization. Orthotics are NOT covered | - | - |
| Oregon | Yes | CN | No | PA required, coverage based upon the prioritized list of health services | - | - |
| Pennsylvania | Yes | CN | Sliding scale based on the Medicaid fee for the service: $0.65 - $3.80 | PA required. Orthopedic Shoes and Hearing Aids are not covered. Eye ocular limited to 1 per calendar year. | - | - |
| Rhode Island | Yes | CN | No | PA required. | - | - |
| South Carolina | NR | NR | NR | NR | - | - |
| South Dakota | Yes | CN | 5% of payment | Orthopedic shoes must be attached to brace | - | - |
| Tennessee | Yes | CN | No | No | - | - |
| Texas | Yes | CN | No | Requires prior authorization. | - | - |
| Utah | Yes | CN | No | 1 every 5 years | - | - |
| Vermont | Yes | CN | No | Prosthetic devices are covered only by prior authorization except for breast prostheses, trusses, and prosthetic socks which require only a physician’s order. Augmentative communication devices are covered for all beneficiaries when medically necessary, with prior authorization. Wheelchairs are covered, with limitations. | - | - |
| Virginia | Yes | CN | No | NR | - | - |
| Washington | Yes | CN | No | Requires PA | - | - |
| West Virginia | Yes | CN | No | Yes - Not Specified | - | - |
| Wisconsin | Yes | CN | $0.50 - $3.00 per service | Some items require prior approval | - | - |
| Wyoming | Yes | CN | No | Some devices require prior authorization | - | - |
2012
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 54 No - 2 | Yes - 13 No - 41 | ||||
| Alabama | Yes | CN | $.50-$3/service or item, depending on payment | Limited to basic level prosthetic and orthotic devices determined medically necessary; prosthetic eyes or lenses, devices to close oral cavity created by congenital defect or surgery, internal life-supporting devices are also covered | Yes | Reasonable charge using Medicare payment ceilings |
| Alaska | Yes | CN | Fee for service based on Medicare fee schedule | |||
| American Samoa | Yes | See territory-specific FN | Prosthetics are limited to artificial cardiac valves, pacemakers and intraocular lenses for cataracts | |||
| Arizona | Yes | CN & MN | Most orthotics as well as bone-anchored hearing aids and cochlear implants not covered but supplies and repairs covered; microprocessor-controlled lower limbs and joints not covered | Specified services or items, items costing more than established amounts | Fee for service | |
| Arkansas | Yes | CN & MN | Orthotic appliances limited to $3,000/year, prosthetic devices limited to $20,000/year | Augmentative communication devices | Fee for service, some items paid percentage of item invoice cost | |
| California | Yes | CN & MN | Limited to services and items to restore function | Specified services or items | Fee for service | |
| Colorado | Yes | CN | $1/date of service | Specified services or items | Fee for service, some items paid retail price minus 22.97% or invoice cost plus 12.71% | |
| Connecticut | Yes | CN & MN | Orthotic and corrective arch supports once/2 years | Yes | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Florida | Yes | CN & MN | Specified services or items | Fee for service | ||
| Georgia | Yes | CN & MN | $3/service | Orthopedic shoes must be attached to brace | Prosthetics and other specified items | Fee for service at 80% of CMS 2007 rates |
| Guam | Yes | CN | Limited to cardiac devices and intraocular lenses for cataracts | Fee for service using Medicare fee schedule | ||
| Hawaii | Yes | CN & MN | Services or items costing more than $50 | Fee for service | ||
| Idaho | Yes | CN | Yes | Fee for service or cost plus 10% | ||
| Illinois | Yes | CN & MN | Specified services or items | Lower of charge or acquisition cost | ||
| Indiana | Yes | CN | Limitations vary by specific device | Yes | Fee for service | |
| Iowa | Yes | CN & MN | $2/day | Cranial orthotic device | Fee for service | |
| Kansas | Yes | CN & MN | $3/service or item | Reasonable charge with limits | ||
| Kentucky | Yes | A, B & C - See state-specific FN | $1,500 limit per year | Fee for service using Medicare payment ceilings | ||
| Louisiana | Yes | CN & MN | Items only replaced if change in physical condition, wear or fit makes them unserviceable, items not covered for ICF/MR residents outside per diem | Yes | Fee for service | |
| Maine | Yes | CN & MN | $.50-$3/day for equipment only, depending on payment, up to $30/month | Limitations vary by service or item | Custom prosthetics and orthotics | Fee for service |
| Maryland | Yes | CN & MN | Prosthetic replacement limits vary by type | Devices costing more than $1,000 | Fee for service | |
| Massachusetts | Yes | CN & MN | Non-medical items and services not covered | Fee for service | ||
| Michigan | Yes | CN & MN | Specified services or items | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | Specified services | Fee for service using Medicare rates where available | ||
| Mississippi | No | |||||
| Missouri | Yes | CN | Specified services | Fee for service | ||
| Montana | Yes | A - See state-specific FN | $5/service or item | Orthopedic shoes must be attached to brace | Services or items costing more than $1,000 | Fee for service or percentage of charge |
| Nebraska | Yes | CN & MN | Fee for service | |||
| Nevada | Yes | CN | Specified services/items | Fee for service | ||
| New Hampshire | Yes | CN & MN | Fee for service | |||
| New Jersey | Yes | CN & MN | Yes | Fee for service | ||
| New Mexico | Yes | CN | Most items covered only once/3 years, orthopedic shoes must be attached to brace, A - cochlear implants not covered | Specified services or items | Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage | |
| New York | Yes | CN & MN | Specified services or items | Fee for service | ||
| North Carolina | Yes | CN & MN | Frequency and quantity limits vary by service | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Specified services or items and other items costing more than $750 | Fee for service | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | Repairs | |||
| Ohio | Yes | CN | Specified items and repairs costing more than $120 | Fee for service, some items paid percentage of item's list price | ||
| Oklahoma | Yes | CN | $3/visit | Limited to specified items | Yes | Fee for service |
| Oregon | Yes | A - See state-specific FN | A & B - services limited to funded conditions on the priority list B - limited to selected items | Specified services or items | Fee for service, using a percentage of Medicare rates | |
| Pennsylvania | Yes | CN | $.65-$3.80/service, depending on payment rate | Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply | Yes | Fee for service |
| Puerto Rico | Yes | CN & MN | Yes | Service is included in the capitated rate paid to managed care plans | ||
| Rhode Island | Yes | See state-specific FN | Yes | Reasonable charge with ceilings | ||
| South Carolina | Yes | CN | $3.40/provider/day | Fee for service using Medicare payment ceilings | ||
| South Dakota | Yes | CN | 5% of payment | Orthopedic shoes must be attached to brace | Percentage of charge | |
| Tennessee | Yes | A, B & C - See state-specific FN | See state-specific FN | |||
| Texas | Yes | CN & MN | Limited to breast prostheses | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | C - 10% of payment | C - orthotics not covered | Fee for service | |
| Vermont | Yes | A & B - See state-specific FN | B - only covered under PC Plus | Specified services or items | Fee for service | |
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Limits vary by service | Yes | Fee for service | |
| Washington | Yes | CN & MN | Specified services or items | Fee for service | ||
| West Virginia | Yes | A, B & C | Specified services | Fee for service using a percentage of Medicare rates | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service or item | Specified services or items, items costing more than established amounts | Fee for service | |
| Wyoming | Yes | CN | Selected items and services | Fee for service |
2010
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 54 No - 2 | Yes - 12 No - 42 | ||||
| Alabama | Yes | CN | Limited to basic level prosthetic and orthotic devices determined medically necessary; prosthetic eyes or lenses, devices to close oral cavity created by congenital defect or surgery, internal life-supporting devices are also covered | Yes | Reasonable charge using Medicare payment ceilings | |
| Alaska | Yes | CN | Fee for service | |||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Most orthotics as well as bone-anchored hearing aids and cochlear implants not covered but supplies and repairs covered; microprocessor-controlled lower limbs and joints not covered | Specified services or items, items costing more than established amounts | Fee for service | |
| Arkansas | Yes | CN & MN | Orthotic appliances limited to $3,000/year, prosthetic devices limited to $20,000/year | Augmentative communication devices | Fee for service, some items paid percentage of item invoice cost | |
| California | Yes | CN & MN | Limited to services and items to restore function | Specified services or items | Fee for service | |
| Colorado | Yes | CN | $1/date of service | Specified services or items | Fee for service, some items paid invoice cost plus 13.56% | |
| Connecticut | Yes | CN & MN | Orthotic and corrective arch supports once/2 years | Yes | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Florida | Yes | CN & MN | Specified services or items | Fee for service | ||
| Georgia | Yes | CN & MN | $3/service | Orthopedic shoes must be attached to brace | Prosthetics and other specified items | Fee for service at 80% of CMS 2007 rates |
| Guam | Yes | CN | Limited to cardiac devices and intraocular lenses for cataracts | Fee for service | ||
| Hawaii | Yes | CN & MN | Services or items costing more than $50 | Fee for service | ||
| Idaho | Yes | CN | Yes | Fee for service or cost plus 10% | ||
| Illinois | Yes | CN & MN | Specified services or items | Lower of charge or acquisition cost | ||
| Indiana | Yes | CN | Yes | Fee for service | ||
| Iowa | Yes | CN & MN | $2/day | Fee for service | ||
| Kansas | Yes | CN & MN | $3/service or item | Reasonable charge with limits | ||
| Kentucky | Yes | A, B & C - See state-specific FN | Fee for service using Medicare payment ceilings | |||
| Louisiana | Yes | CN & MN | Yes | Fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day for equipment only, depending on payment, up to $30/month | Limitations vary by service or item | Custom prosthetics and orthotics | Fee for service |
| Maryland | Yes | CN & MN | Prosthetic replacement limits vary by type | Fee for service | ||
| Massachusetts | Yes | CN & MN | Non-medical items and services not covered | Fee for service | ||
| Michigan | Yes | CN & MN | Specified services or items | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | Specified services | Fee for service using Medicare rates where available | ||
| Mississippi | No | |||||
| Missouri | Yes | CN | Adult coverage other than for pregnant or blind does not include orthotics unless provided through home health plan of care | Specified services | Fee for service | |
| Montana | Yes | A - See state-specific FN | $5/service or item | Orthopedic shoes must be attached to brace | Services or items costing more than $1,000 | Fee for service or percentage of charge |
| Nebraska | Yes | CN & MN | Fee for service | |||
| Nevada | Yes | CN | Specified services/items | Fee for service | ||
| New Hampshire | Yes | CN & MN | Fee for service | |||
| New Jersey | Yes | CN & MN | Limited to post-trauma care or to treat gross deformities, 3 home visits to fit appliance | Yes | Fee for service | |
| New Mexico | Yes | CN | Most items covered only once/3 years, orthopedic shoes must be attached to brace, A - cochlear implants not covered | Specified services or items | Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage | |
| New York | Yes | CN & MN | Specified services or items | Fee for service | ||
| North Carolina | Yes | CN & MN | Frequency and quantity limits vary by service | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Specified services or items and other items costing more than $750 | Fee for service | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | Specified items and repairs costing more than $120 | Fee for service, some items paid percentage of item's list price | ||
| Oklahoma | Yes | CN | $3/visit | Limited to specified items | Yes | Fee for service |
| Oregon | Yes | A - See state-specific FN | A & B - services limited to funded conditions on the priority list B - limited to selected items | Specified services or items | Fee for service, using a percentage of Medicare rates | |
| Pennsylvania | Yes | CN | $.50-$3/service, depending on payment rate | Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply | Yes | Fee for service |
| Puerto Rico | Yes | CN & MN | Yes | Service is included in the capitated rate paid to managed care plans | ||
| Rhode Island | Yes | See state-specific FN | Yes | Reasonable charge with ceilings | ||
| South Carolina | Yes | CN | $3/provider/day | Fee for service using Medicare payment ceilings | ||
| South Dakota | Yes | CN | 5% of payment | Orthopedic shoes must be attached to brace | Percentage of charge | |
| Tennessee | Yes | A & B - See state-specific FN | See state-specific FN | |||
| Texas | Yes | CN & MN | Adult coverage limited to nursing facility and ICF/MR residents | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | C - 10% of payment | C - orthotics not covered | Fee for service | |
| Vermont | Yes | A & B - See state-specific FN | B - only covered under PC Plus | Specified services or items | Fee for service | |
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Limits vary by service | Yes | Fee for service | |
| Washington | Yes | CN & MN | Specified services or items | Fee for service | ||
| West Virginia | Yes | A, B & C | Specified services | Fee for service using a percentage of Medicare rates | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service or item | Limited to post-surgery care, orthopedic shoes must be attached to brace | Specified services or items, items costing more than established amounts | Fee for service |
| Wyoming | Yes | CN | Fee for service |
2008
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 54 No - 2 | Yes - 10 No - 44 | ||||
| Alabama | Yes | CN | Limited to basic level prosthetic and orthotic devices determined medically necessary; prosthetic eyes or lenses, devices to close oral cavity created by congenital defect or surgery, internal life-supporting devices are also covered | Yes | Reasonable charge using Medicare payment ceilings | |
| Alaska | Yes | CN | Fee for service | |||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified services or items, items costing more than established amounts | Fee for service | ||
| Arkansas | Yes | CN & MN | Orthotic appliances limited to $3,000/year, prosthetic devices limited to $20,000/year | Augmentative communication devices | Fee for service, some items paid percentage of item invoice cost | |
| California | Yes | CN & MN | Limited to services and items to restore function | Specified services or items | Fee for service | |
| Colorado | Yes | CN | Specified services or items | Fee for service, some items paid acquisition cost plus 20% | ||
| Connecticut | Yes | CN & MN | Orthotic and corrective arch supports once/2 years | Yes | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Florida | Yes | CN & MN | Specified services or items | Fee for service | ||
| Georgia | Yes | CN & MN | $3/service | Orthopedic shoes must be attached to brace | Prosthetics and other specified items | Fee for service at 80% of CMS 2007 rates |
| Guam | Yes | CN | Limited to cardiac devices and intraocular lenses for cataracts | Fee for service | ||
| Hawaii | Yes | CN & MN | Services or items costing more than $50 | Fee for service | ||
| Idaho | Yes | CN | Yes | Fee for service | ||
| Illinois | Yes | CN & MN | Specified services or items | Lower of charge or acquisition cost | ||
| Indiana | Yes | CN | Yes | Fee for service | ||
| Iowa | Yes | CN & MN | $2/day | Fee for service | ||
| Kansas | Yes | CN & MN | $3/service or item | Reasonable charge with limits | ||
| Kentucky | Yes | A, B & C - See state-specific FNN | Fee for service using Medicare payment ceilings | |||
| Louisiana | Yes | CN & MN | Yes | Fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | 1 pair orthotic shoes and 1 pair shoe inserts/year | Specified items costing more than $500 | Fee for service |
| Maryland | Yes | CN & MN | Prosthetic replacements limited to once/3 years, orthotics not covered | Fee for service | ||
| Massachusetts | Yes | CN & MN | Non-medical items and services not covered | Fee for service | ||
| Michigan | Yes | CN & MN | Specified services or items | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | Specified services | Fee for service using Medicare rates where available | ||
| Mississippi | No | |||||
| Missouri | Yes | CN | Adult coverage other than for pregnant or blind does not include orthotics unless provided through home health plan of care | Specified services | Fee for service | |
| Montana | Yes | A - See state-specific FN | $5/service or item | Orthopedic shoes must be attached to brace | Services or items costing more than $1,000 | Fee for service or percentage of charge |
| Nebraska | Yes | CN & MN | Fee for service | |||
| Nevada | Yes | CN | Specified services/items | Fee for service | ||
| New Hampshire | Yes | CN & MN | Fee for service | |||
| New Jersey | Yes | CN & MN | Limited to post-trauma care or to treat gross deformities, 3 home visits to fit appliance | Yes | Fee for service | |
| New Mexico | Yes | CN | Most items covered only once/3 years, orthopedic shoes must be attached to brace | Specified services or items | Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage | |
| New York | Yes | CN & MN | Specified services or items | Fee for service | ||
| North Carolina | Yes | CN & MN | Frequency and quantity limits vary by service | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Services or items costing more than $500 | Fee for service | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | Orthopedic shoes must be attached to brace and are limited to 2 pair/year | Specified items and repairs costing more than $120 | Fee for service, some items paid percentage of item's list price | |
| Oklahoma | Yes | CN | Limited to specified items | Yes | Fee for service | |
| Oregon | Yes | A - See state-specific FN | Specified services or items | Fee for service | ||
| Pennsylvania | Yes | CN | $.50-$3/service, depending on payment rate | Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply | Yes | Fee for service |
| Puerto Rico | Yes | CN & MN | Yes | Negotiated fee | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Reasonable charge with ceilings | ||
| South Carolina | Yes | CN | $3/provider/day | Fee for service using Medicare payment ceilings | ||
| South Dakota | Yes | CN | 5% of payment | Orthopedic shoes must be attached to brace | Percentage of charge | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | Yes | CN & MN | Adult coverage limited to NF and ICF/MR residents | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | C - 10% of payment | B & C - orthotics not covered | Fee for service | |
| Vermont | Yes | A & B - See state-specific FN | B - only covered under PC Plus | Specified services or items | Fee for service | |
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Limits vary by service | Yes | Fee for service | |
| Washington | Yes | CN & MN | Specified services or items | Fee for service | ||
| West Virginia | Yes | A, B & C | Specified services | Fee for service using a percentage of Medicare rates | ||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service or item | Limited to post-surgery care, orthopedic shoes must be attached to brace | Specified services or items, items costing more than established amounts | Fee for service |
| Wyoming | Yes | CN | Fee for service |
2006
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 54 No - 2 | Yes - 10 No - 44 | ||||
| Alabama | Yes | CN | Limited to prosthetic eyes or lenses, devices to close oral cavity created by congenital defect or surgery, internal life-supporting devices only | Reasonable charge using Medicare payment ceilings | ||
| Alaska | Yes | CN | Fee for service | |||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified services or items, items costing more than established amounts | Fee for service | ||
| Arkansas | Yes | CN & MN | Orthotic appliances limited to $3,000/year, prosthetic devices limited to $20,000/year | Augmentative communication devices | Fee for service, some items paid percentage of item invoice cost | |
| California | Yes | CN & MN | Limited to services and items to restore function | Specified services or items | Fee for service | |
| Colorado | Yes | CN | Specified services or items | Fee for service, some items paid acquisition cost plus 20% | ||
| Connecticut | Yes | CN & MN | Orthotic and corrective arch supports once/2 years | Yes | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Florida | Yes | CN & MN | Specified services or items | Fee for service | ||
| Georgia | Yes | CN & MN | $3/service | Orthopedic shoes must be attached to brace | Prosthetics and other specified items | Fee for service |
| Guam | Yes | CN | Limited to cardiac devices and intraocular lenses for cataracts | Fee for service | ||
| Hawaii | Yes | CN & MN | Services or items costing more than $50 | Fee for service | ||
| Idaho | Yes | CN | Yes | Fee for service | ||
| Illinois | Yes | CN & MN | Specified services or items | Lower of charge or acquisition cost | ||
| Indiana | Yes | CN | Yes | Fee for service | ||
| Iowa | Yes | CN & MN | $2/day | Fee for service | ||
| Kansas | Yes | CN & MN | $3/service or item | Reasonable charge with limits | ||
| Kentucky | Yes | A, B & C - See state-specific FN | Fee for service using Medicare payment ceilings | |||
| Louisiana | Yes | CN & MN | Yes | Fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | 1 pair orthotic shoes and 1 pair shoe inserts/year | Specified items costing more than $500 | Fee for service |
| Maryland | Yes | CN & MN | Prosthetic replacements limited to once/3 years, orthotics not covered | Fee for service | ||
| Massachusetts | Yes | CN & MN | Non-medical items and services not covered | Fee for service | ||
| Michigan | Yes | CN & MN | Specified services or items | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | Specified services | Fee for service using Medicare rates where available | ||
| Mississippi | No | |||||
| Missouri | Yes | CN | Adult coverage other than for pregnant or blind does not include orthotics unless provided through home health plan of care | Yes | Fee for service | |
| Montana | Yes | A - See state-specific FN | $5/service or item | Orthopedic shoes must be attached to brace | Services or items costing more than $1,000 | Fee for service or percentage of charge |
| Nebraska | Yes | CN & MN | Products with computerized components not covered | Fee for service | ||
| Nevada | Yes | CN | Yes | Fee for service | ||
| New Hampshire | Yes | CN & MN | Specified services or items | Fee for service | ||
| New Jersey | Yes | CN & MN | Limited to post-trauma care or to treat gross deformities, orthopedic shoes must be attached to brace, 3 home visits to fit appliance | Yes | Fee for service | |
| New Mexico | Yes | CN | Most items covered only once/3 years, orthopedic shoes must be attached to brace | Specified services or items | Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage | |
| New York | Yes | CN & MN | Specified services or items | Fee for service | ||
| North Carolina | Yes | CN & MN | Frequency and quantity limits vary by service | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Services or items costing more than $300 | Fee for service using a percentage of Medicare allowable cost as ceiling | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | Orthopedic shoes must be attached to brace and are limited to 2 pair/year | Specified items and repairs costing more than $120 | Fee for service, some items paid percentage of item's list price | |
| Oklahoma | Yes | CN | Limited to specified items | Fee for service | ||
| Oregon | Yes | A - See state-specific FN | Specified services or items | Fee for service | ||
| Pennsylvania | Yes | CN | $.50-$3/service, depending on payment | Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply | Yes | Fee for service |
| Puerto Rico | Yes | CN & MN | Yes | Negotiated fee | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Reasonable charge with ceilings | ||
| South Carolina | Yes | CN | $3/provider/day | Fee for service using Medicare payment ceilings | ||
| South Dakota | Yes | CN | 5% of payment | Orthopedic shoes must be attached to brace | Percentage of charge | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | Yes | CN & MN | Adult coverage limited to NF and ICF/MR residents | Fee for service | ||
| Utah | Yes | A, B & C - See state-specific FN | C - 10% of payment | B & C - orthotics not covered | Fee for service | |
| Vermont | Yes | A & B - See state-specific FN | B - only covered under PC Plus | Specified services or items | Fee for service | |
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Yes | Fee for service | ||
| Washington | Yes | CN & MN | Specified services or items | Fee for service | ||
| West Virginia | Yes | CN & MN | Fee for service using percentage of Medicare rates | |||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service or item | Limited to post-surgery care, orthopedic shoes must be attached to brace | Specified services or items, items costing more than established amounts | Fee for service |
| Wyoming | Yes | CN | Fee for service |
2004
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 53 No - 3 | Yes - 9 No - 44 | ||||
| Alabama | Yes | CN | Limited to prosthetic eyes or lenses, devices to close oral cavity created by congenital defect or surgery, internal life-supporting devices only | Reasonable charge using Medicare payment ceilings | ||
| Alaska | Yes | CN | Fee for service | |||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified services or items, items costing more than established amounts | Fee for service | ||
| Arkansas | Yes | CN & MN | Orthotic appliances limited to $3,000/year, prosthetic devices limited to $20,000/year | Augmentative communication devices | Fee for service, some items paid percentage of item invoice cost | |
| California | Yes | CN & MN | Limited to services and items to restore function | Specified services or items | Fee for service | |
| Colorado | Yes | CN | Specified services or items | Fee for service, some items paid acquisition cost plus 19% | ||
| Connecticut | Yes | CN & MN | Orthotic and corrective arch supports once/2 years | Yes | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Florida | Yes | CN & MN | Specified services or items | Fee for service | ||
| Georgia | Yes | CN & MN | $3/service | Orthopedic shoes must be attached to brace | Prosthetics and other specified items | Fee for service |
| Guam | Yes | CN | Limited to cardiac devices and intraocular lenses for cataracts | Fee for service | ||
| Hawaii | Yes | CN & MN | Services or items costing more than $50 | Fee for service | ||
| Idaho | Yes | CN | Yes | Fee for service | ||
| Illinois | Yes | CN & MN | Specified services or items | Lower of charge or acquisition cost | ||
| Indiana | Yes | CN | Yes | Fee for service | ||
| Iowa | Yes | CN & MN | $2/day | Fee for service | ||
| Kansas | Yes | CN & MN | $3/service or item | Reasonable charge with limits | ||
| Kentucky | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Louisiana | Yes | CN & MN | Yes | Fee for service | ||
| Maine | Yes | CN & MN | $.50-$2/day, depending on payment, up to $30/month | Specified items costing more than $500 | Fee for service | |
| Maryland | Yes | CN & MN | Prosthetic replacements limited to once/3 years, orthotics not covered | Fee for service | ||
| Massachusetts | Yes | CN & MN | Non-medical items and services not covered | Fee for service | ||
| Michigan | Yes | CN & MN | Specified services or items | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | Specified services | Fee for service using Medicare rates where available | ||
| Mississippi | No | |||||
| Missouri | Yes | CN | Yes | Fee for service | ||
| Montana | Yes | A - See state-specific FN | $5/service or item | Orthopedic shoes must be attached to brace | Services or items costing more than $1,000 | Fee for service or percentage of charge |
| Nebraska | Yes | CN & MN | Products with computerized components not covered | Fee for service | ||
| Nevada | Yes | CN | Yes | Fee for service | ||
| New Hampshire | Yes | CN & MN | Specified services or items | Fee for service | ||
| New Jersey | Yes | CN & MN | Limited to post-trauma care or to treat gross deformities, orthopedic shoes must be attached to brace, 3 home visits to fit appliance | Yes | Fee for service | |
| New Mexico | Yes | CN | Most items covered only once/3 years, orthopedic shoes must be attached to brace | Specified services or items | Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage | |
| New York | Yes | CN & MN | Specified services or items | Fee for service | ||
| North Carolina | Yes | CN & MN | Frequency and quantity limits vary by service | Specified services | Fee for service | |
| North Dakota | Yes | CN & MN | Services or items costing more than $300 | Fee for service using a percentage of Medicare allowable cost as ceiling | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | Orthopedic shoes must be attached to brace and are limited to 2 pair/year | Specified items and new items and repairs costing more than $100 | Fee for service, some items paid percentage of item's list price | |
| Oklahoma | Yes | CN | Limited to specified items | Fee for service | ||
| Oregon | Yes | A - See state-specific FN | Specified services or items | Fee for service | ||
| Pennsylvania | Yes | CN | Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply | Fee for service | ||
| Puerto Rico | Yes | CN & MN | Yes | Negotiated fee | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Reasonable charge with ceilings | ||
| South Carolina | Yes | CN | $3/provider/day | Fee for service using Medicare payment ceilings | ||
| South Dakota | Yes | CN | 5% of payment | Orthopedic shoes must be attached to brace | Percentage of charge | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | No | |||||
| Utah | Yes | A, B & C - See state-specific FN | C - 10% of payment | B & C - orthotics not covered | Fee for service | |
| Vermont | Yes | A & B - See state-specific FN | Specified services or items | Fee for service | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Yes | Fee for service | ||
| Washington | Yes | CN & MN | Specified services or items | Fee for service | ||
| West Virginia | Yes | CN & MN | Fee for service using a percentage of Medicare rates | |||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service or item | Limited to post-surgery care, orthopedic shoes must be attached to brace | Specified services or items, items costing more than established amounts | Fee for service |
| Wyoming | Yes | CN | Fee for service |
2003
| Location | Benefit Covered | Coverage Code | Copayment Required? | Limit on services days | Prior Approval Required | Reimbursement Methodology |
|---|---|---|---|---|---|---|
| United States | Yes - 51 No - 5 | Yes - 8 No - 43 | ||||
| Alabama | Yes | CN | Limited to prosthetic eyes or lenses, devices to close oral cavity created by congenital defect or surgery, internal life-supporting devices only | Reasonable charge using Medicare payment ceilings | ||
| Alaska | Yes | CN | Fee for service | |||
| American Samoa | Yes | See territory-specific FN | ||||
| Arizona | Yes | CN & MN | Specified services or items, items costing more than established amounts | Fee for service | ||
| Arkansas | Yes | CN & MN | Orthotic appliances limited to $3,000/year, prosthetic devices limited to $20,000/year | Augmentative communication devices | Fee for service, some items paid percentage of item invoice cost | |
| California | Yes | CN & MN | Limited to services and items to restore function | Specified services or items | Fee for service | |
| Colorado | Yes | CN | Specified services or items | Fee for service, some items paid acquisition cost plus 20% | ||
| Connecticut | Yes | CN & MN | Orthotic and corrective arch supports once/2 years | Yes | Fee for service | |
| Delaware | Yes | CN | Fee for service | |||
| District of Columbia | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Florida | Yes | CN & MN | Specified services or items | Fee for service | ||
| Georgia | Yes | CN & MN | $3/service | Orthopedic shoes must be attached to brace | Prosthetics and other specified items | Fee for service |
| Guam | Yes | CN | Limited to cardiac devices and intraocular lenses for cataracts | Fee for service | ||
| Hawaii | Yes | CN & MN | Services or items costing more than $50 | Fee for service | ||
| Idaho | Yes | CN | Yes | Fee for service | ||
| Illinois | Yes | CN & MN | Specified services or items | Lower of charge or acquisition cost | ||
| Indiana | Yes | CN | Yes | Fee for service | ||
| Iowa | Yes | CN & MN | $2/day | Fee for service | ||
| Kansas | Yes | CN & MN | $3/service or item | Reasonable charge with limits | ||
| Kentucky | Yes | CN & MN | Fee for service using Medicare payment ceilings | |||
| Louisiana | Yes | CN & MN | Yes | Fee for service | ||
| Maine | Yes | CN & MN | $.50-$3/day, depending on payment, up to $30/month | Specified items costing more than $500 | Fee for service | |
| Maryland | Yes | CN & MN | Prosthetic replacements limited to once/3 years, orthotics not covered | Fee for service | ||
| Massachusetts | No | |||||
| Michigan | Yes | CN & MN | Specified services or items | Fee for service | ||
| Minnesota | Yes | A & B - See state-specific FN | Specified services | Fee for service using Medicare rates where available | ||
| Mississippi | No | |||||
| Missouri | Yes | CN | Yes | Fee for service | ||
| Montana | Yes | CN & MN | $5/service or item | Orthopedic shoes must be attached to brace | Services or items costing more than $1,000 | Fee for service or percentage of charge |
| Nebraska | Yes | CN & MN | Products with computerized components not covered | Fee for service | ||
| Nevada | Yes | CN | Yes | Fee for service | ||
| New Hampshire | Yes | CN & MN | Specified services or items | Fee for service | ||
| New Jersey | Yes | CN & MN | Limited to post-trauma care or to treat gross deformities, orthopedic shoes must be attached to brace, 3 home visits to fit appliance | Yes | Fee for service | |
| New Mexico | Yes | CN | Specified services or items | Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage | ||
| New York | Yes | CN & MN | Specified services or items | Fee for service | ||
| North Carolina | No | |||||
| North Dakota | Yes | CN & MN | Services or items costing more than $300 | Fee for service using a percentage of Medicare allowable cost as ceiling | ||
| Northern Mariana Islands | Yes | CN & MN - See territory-specific FN | ||||
| Ohio | Yes | CN | Orthopedic shoes must be attached to brace and are limited to 2 pair/year | New items and repairs costing more than $100 | Fee for service, some items paid percentage of item's list price | |
| Oklahoma | No | |||||
| Oregon | Yes | CN & MN | Specified services or items | Fee for service | ||
| Pennsylvania | Yes | CN | Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply | Fee for service | ||
| Puerto Rico | Yes | CN & MN | Yes | Negotiated fee | ||
| Rhode Island | Yes | CN & MN - see state-specific FN | Yes | Reasonable charge with ceilings | ||
| South Carolina | Yes | CN | Fee for service using Medicare payment ceilings | |||
| South Dakota | Yes | CN | 5% of payment | Orthopedic shoes must be attached to brace | Percentage of charge | |
| Tennessee | Yes | A & B - See state-specific FN | ||||
| Texas | Yes | CN & MN | Specified services or items | Fee for service | ||
| Utah | Yes | A, B & C - See state specific FN | C - 10% of payment | B & C - orthotics not covered | Fee for service | |
| Vermont | Yes | A & B - See state-specific FN | Specified services or items | Fee for service | ||
| U.S. Virgin Islands | No | |||||
| Virginia | Yes | CN & MN | Yes | Fee for service | ||
| Washington | Yes | CN & MN | Specified services or items | Fee for service | ||
| West Virginia | Yes | CN & MN | Fee for service | |||
| Wisconsin | Yes | CN & MN | $.50-$3, depending on service or item | Limited to post-surgery care, orthopedic shoes must be attached to brace | Specified services or items, items costing more than established amounts | Fee for service |
| Wyoming | Yes | CN | Fee for service |