| Is the Benefit Covered? |
Copayment Requirement |
Prior Approval Requirement |
Coverage Limitations |
Reimbursement Methodology |
Populations Covered |
|
|
Alabama
|
|
Yes
|
|
Yes
|
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
|
Reasonable charge using Medicare payment ceilings
|
CN
|
|
Alaska
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
Arizona
|
|
Yes
|
|
Specified services or items, items costing more than established amounts
|
|
Fee for service
|
CN & MN
|
|
Arkansas
|
|
Yes
|
|
Augmentative communication devices
|
Orthotic appliances limited to $3,000/year, prosthetic devices limited to $20,000/year
|
Fee for service, some items paid percentage of item invoice cost
|
CN & MN
|
|
California
|
|
Yes
|
|
Specified services or items
|
Limited to services and items to restore function
|
Fee for service
|
CN & MN
|
|
Colorado
|
|
Yes
|
|
Specified services or items
|
|
Fee for service, some items paid acquisition cost plus 20%
|
CN
|
|
Connecticut
|
|
Yes
|
|
Yes
|
Orthotic and corrective arch supports once/2 years
|
Fee for service
|
CN & MN
|
|
Delaware
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
District of Columbia
|
|
Yes
|
|
|
|
Fee for service using Medicare payment ceilings
|
CN & MN
|
|
Florida
|
|
Yes
|
|
Specified services or items
|
|
Fee for service
|
CN & MN
|
|
Georgia
|
|
Yes
|
$3/service
|
Prosthetics and other specified items
|
Orthopedic shoes must be attached to brace
|
Fee for service at 80% of CMS 2007 rates
|
CN & MN
|
|
Hawaii
|
|
Yes
|
|
Services or items costing more than $50
|
|
Fee for service
|
CN & MN
|
|
Idaho
|
|
Yes
|
|
Yes
|
|
Fee for service
|
CN
|
|
Illinois
|
|
Yes
|
|
Specified services or items
|
|
Lower of charge or acquisition cost
|
CN & MN
|
|
Indiana
|
|
Yes
|
|
Yes
|
|
Fee for service
|
CN
|
|
Iowa
|
|
Yes
|
$2/day
|
|
|
Fee for service
|
CN & MN
|
|
Kansas
|
|
Yes
|
$3/service or item
|
|
|
Reasonable charge with limits
|
CN & MN
|
|
Kentucky
|
|
Yes
|
|
|
B - $1500 maximum benefit/year
|
Fee for service using Medicare payment ceilings
|
A, B, C & D - See state-specific FN
|
|
Louisiana
|
|
Yes
|
|
Yes
|
|
Fee for service
|
CN & MN
|
|
Maine
|
|
Yes
|
$.50-$3/day, depending on payment, up to $30/month
|
Specified items costing more than $500
|
1 pair orthotic shoes and 1 pair shoe inserts/year
|
Fee for service
|
CN & MN
|
|
Maryland
|
|
Yes
|
|
|
Prosthetic replacements limited to once/3 years, orthotics not covered
|
Fee for service
|
CN & MN
|
|
Massachusetts
|
|
Yes
|
|
|
Non-medical items and services not covered
|
Fee for service
|
CN & MN
|
|
Michigan
|
|
Yes
|
|
Specified services or items
|
|
Fee for service
|
CN & MN
|
|
Minnesota
|
|
Yes
|
|
Specified services
|
|
Fee for service using Medicare rates where available
|
A & B - See state-specific FN
|
|
Mississippi
|
|
No
|
|
|
|
|
|
|
Missouri
|
|
Yes
|
|
Specified services
|
Adult coverage other than for pregnant or blind does not include orthotics unless provided through home health plan of care
|
Fee for service
|
CN & MN
|
|
Montana
|
|
Yes
|
$5/service or item
|
Services or items costing more than $1,000
|
Orthopedic shoes must be attached to brace
|
Fee for service or percentage of charge
|
A - See state-specific FN
|
|
Nebraska
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
Nevada
|
|
Yes
|
|
Specified services/items
|
|
Fee for service
|
CN
|
|
New Hampshire
|
|
Yes
|
|
|
|
Fee for service
|
CN & MN
|
|
New Jersey
|
|
Yes
|
|
Yes
|
Limited to post-trauma care or to treat gross deformities, orthopedic shoes must be attached to brace, 3 home visits to fit appliance
|
Fee for service
|
CN & MN
|
|
New Mexico
|
|
Yes
|
|
Specified services or items
|
Most items covered only once/3 years, orthopedic shoes must be attached to brace
|
Fee for service using Medicare payment ceilings, some items paid invoice cost plus percentage
|
CN
|
|
New York
|
|
Yes
|
|
Specified services or items
|
|
Fee for service
|
CN & MN
|
|
North Carolina
|
|
Yes
|
|
Specified services
|
Frequency and quantity limits vary by service
|
Fee for service
|
CN & MN
|
|
North Dakota
|
|
Yes
|
|
Services or items costing more than $500
|
|
Fee for service
|
CN & MN
|
|
Ohio
|
|
Yes
|
|
Specified items and repairs costing more than $120
|
Orthopedic shoes must be attached to brace and are limited to 2 pair/year
|
Fee for service, some items paid percentage of item's list price
|
CN
|
|
Oklahoma
|
|
Yes
|
|
Yes
|
Limited to specified items
|
Fee for service
|
CN
|
|
Oregon
|
|
Yes
|
|
Specified services or items
|
|
Fee for service
|
A - See state-specific FN
|
|
Pennsylvania
|
|
Yes
|
$.50-$3/service, depending on payment rate
|
Yes
|
Limited to orthopedic shoe inserts and selected orthotics, specified frequency and quantity limits apply
|
Fee for service
|
CN
|
|
Rhode Island
|
|
Yes
|
|
Yes
|
|
Reasonable charge with ceilings
|
CN & MN - see state-specific FN
|
|
South Carolina
|
|
Yes
|
$3/provider/day
|
|
|
Fee for service using Medicare payment ceilings
|
CN
|
|
South Dakota
|
|
Yes
|
5% of payment
|
|
Orthopedic shoes must be attached to brace
|
Percentage of charge
|
CN
|
|
Tennessee
|
|
Yes
|
|
|
|
|
A & B - See state-specific FN
|
|
Texas
|
|
Yes
|
|
|
Adult coverage limited to NF and ICF/MR residents
|
Fee for service
|
CN & MN
|
|
Utah
|
|
Yes
|
C - 10% of payment
|
|
B & C - orthotics not covered
|
Fee for service
|
A, B & C - See state-specific FN
|
|
Vermont
|
|
Yes
|
|
Specified services or items
|
B - only covered under PC Plus
|
Fee for service
|
A & B - See state-specific FN
|
|
Virginia
|
|
Yes
|
|
Yes
|
Limits vary by service
|
Fee for service
|
CN & MN
|
|
Washington
|
|
Yes
|
|
Specified services or items
|
|
Fee for service
|
CN & MN
|
|
West Virginia
|
|
Yes
|
|
Specified services
|
|
Fee for service
|
A & B
|
|
Wisconsin
|
|
Yes
|
$.50-$3, depending on service or item
|
Specified services or items, items costing more than established amounts
|
Limited to post-surgery care, orthopedic shoes must be attached to brace
|
Fee for service
|
CN & MN
|
|
Wyoming
|
|
Yes
|
|
|
|
Fee for service
|
CN
|
|
American Samoa
|
|
Yes
|
|
|
|
|
See territory-specific FN
|
|
Guam
|
|
Yes
|
|
|
Limited to cardiac devices and intraocular lenses for cataracts
|
Fee for service
|
CN
|
|
Northern Mariana Islands
|
|
Yes
|
|
|
|
|
CN & MN - See territory-specific FN
|
|
Puerto Rico
|
|
Yes
|
|
Yes
|
|
Negotiated fee
|
CN & MN
|
|
Virgin Islands
|
|
No
|
|
|
|
|
|
