Medical Equipment - Orthoses

Overview

The least expensive, appropriate orthoses may be provided to eligible clients to meet a medically essential need. There must be no other resources available to the client to provide the item requested. 

Orthoses are items that are applied externally to the limb or body to provide support, protection or replacement of lost function. They are also commonly known as an orthosis, orthotic, brace, or splint. 

Other programs and resources:

Supports and Services – Assistive Technology

Information regarding other supports and services, including resources for assistive technology, can be found on the Accessibility website.

Equipment and Assistive Technology Initiative

The Equipment and Assistive Technology Initiative (EATI) program ended on August 29, 2014. The Ministry of Social Development and Social Innovation (SDSI) will fund equipment/technology repairs for all former participants until March 31, 2015.

Participants should contact the vendor who provided the equipment to them.  The vendor can submit a quote for repairs to the ministry through the contact information below.

The ministry will review the request based on the EATI guidelines and the individual will be notified about the status of the request by mail. If participants have any questions, they should contact the ministry. 

Ministry of Social Development and Social Innovation contact information:

  • Email: SDSIEATI@gov.bc.ca
  • Mail: PO Box 9929 Stn Prov Govt  EATI Repairs Victoria BC V8W 9R2
  • Phone: Leave a message at 250-387-8725 (to avoid long distance charges outside Victoria, call through Enquiry BC: 1 800 663-7867. Telephone Device for the Deaf: 1 800 661-8773).

The ministry expects to refer participants to other programs and services after March 31, 2015.

People with disabilities can access assistive technologies through WorkBC to help them find a job, or if they need a piece of equipment to keep working at their current job. WorkBC provides employment related:

  • assistive devices, equipment and technology
  • communication and hearing devices
  • ergonomic supports and other personal devices
  • interpreting and captioning services
  • workplace access and modification

Note: The ministry continues to provide orthoses for eligible recipients. For more information, see Policy in this topic.

Policy

Effective: October 1, 2012

By regulation, orthoses include only the following items:
 

  • a custom-made foot orthotic
  • an off-the-shelf foot orthotic
  • custom-made footwear
  • off-the-shelf orthopaedic footwear
  • off-the-shelf footwear
  • a permanent modification to footwear
  • an ankle brace
  • an ankle-foot orthosis
  • a knee-ankle-foot orthosis
  • a knee brace
  • a hip brace
  • an upper extremity brace
  • a cranial helmet
  • a torso or spine brace
  • a foot abduction orthosis
  • a toe orthosis
  • orthosis accessories and supplies

[For information on eligibility for hearing aids and other medical equipment, see Related Links – Medical Equipment – Hearing Aids and Medical Equipment and Devices.]

Effective: October 1, 2012

Orthoses are available to clients who are eligible for general health supplements. [For information on eligibility for general health supplements, see Related Links - Health Supplement Summary.] Clients living in Ministry of Health funded residential care facilities may also be considered. 

A requested item must meet the following:
 

  • General Requirements for All Orthoses;

and

  • Specific Requirements for each Individual Type of Orthosis.

General Requirements for All Orthoses 

A client requesting orthoses must meet the general requirements that apply to all orthoses:
 

  • there are no resources available to the family unit to pay the cost of or obtain the item;
  • the item is the least expensive, appropriate orthosis;
  • only one orthosis per part of the body may be considered;

Note: one “resting” orthosis may also be considered for each part of the body.
 

  • the item must be prescribed by a medical practitioner or nurse practitioner;
  • the request must be pre-approved by the ministry prior to purchase;

Note: the ministry will not accept payment responsibility, except in cases of a life-threatening emergency, for orthoses purchased without prior approval.
 

  • the ministry is satisfied that the item is medically essential to achieve or maintain basic functionality;
  • the item is required for one or more of the following purposes:
    • to prevent surgery
    • for post-surgical care
    • to assist in physical healing from surgery, injury or disease
    • to improve physical functioning that has been impaired by a neuro-musculo-skeletal condition
  • custom-made items will be considered when the following are met:
    • a medical practitioner or nurse practitioner confirms that a custom-made orthosis is medically required;
    • the custom-made orthosis is fitted by a certified orthotist, certified pedorthist, occupational therapist, physical therapist, or podiatrist.

Specific Requirements for each Individual Type of Orthosis

In addition to meeting the general requirements for all orthoses, a client must also meet the specific requirements for the requested type of item:

Note: not all orthoses have specific requirements

Type of Item

Specific Requirements

Custom-made Foot Orthotics

  • they must be made from a hand-cast mold
  • the cost of one pair, including the assessment fee, must not exceed $450

Off-the-shelf Orthopaedic Footwear

  • the cost of one pair must not exceed $250
  • “off-the-shelf orthopaedic footwear” means footwear intentionally designed to accommodate a medical condition

Off-the-shelf Footwear

  • the cost of one pair must not exceed $125
  • must be required to accommodate a custom-made orthosis
  • “off-the-shelf footwear” means conventional, non-orthopaedic footwear

Custom-made Footwear

  • the cost, including the assessment fee, must not exceed $1,650

Knee Brace

  • the medical practitioner or nurse practitioner who prescribed the knee brace must recommend that the knee brace must be worn at least 6 hours per day.

Upper Extremity Brace

  • the upper extremity brace must be intended to provide hand, finger, wrist, elbow or shoulder support

Cranial Helmet

  • must be a helmet prescribed by a medical practitioner or nurse practitioner and recommended for daily use in cases of self-abusive behaviour, seizure disorder, or to protect or facilitate healing of chronic wounds or cranial defects

Torso or Spine Brace

  • must be intended to provide pelvic, lumbar, lumbar-sacral, thoracic-lumbar-sacral, cervical-thoracic-lumbar-sacral, or cervical spine support

Orthosis Accessories and Supplies

  • only for orthoses that meet eligibility criteria
  • must be medically essential for the use of the orthosis
  • an example item is a brace under sleeve for skin protection
  • up to 4 per orthosis may be provided each year

Effective: August 2, 2011

The ministry does not provide orthoses that do not meet the eligibility criteria above, including the following:
 

  • a prosthetic and related supplies
  • a plaster or fibreglass cast
  • a hernia support
  • an abdominal support
  • a walking boot for a fracture

Effective: April 1, 2010

By regulation, the ministry is the payer of last resort and requires that all other available resources must first be considered before requesting funding. For income assistance and disability assistance clients, other resources include (but are not limited to) accessing orthoses or funding through:
 

  • other government programs (e.g., PharmaCare, Health Authorities, ICBC, WorkSafeBC, Veterans Affairs Canada)
  • private insurance

If there are other resources available, the individual is not eligible for orthoses from the ministry. 

Co-funding may be considered when other resources cannot pay the entire cost. For example, if an insurance company will pay $500 for an item that costs $1,000, the ministry may consider funding the remaining $500 if all other eligibility criteria are met.

Note: When assessing orthoses eligibility for income or disability assistance clients, exempt assets are not considered. When assessing other resources for persons with a life-threatening health need or persons who are medical services only, see Related Links –Life-Threatening Health Needs and Medical Services Only.

Effective: April 1, 2010

The following guidelines outline factors considered by the ministry when determining if orthoses requests are medically essential to achieve or maintain basic functionality. 

These guidelines assist ministry staff when reviewing the information provided by the client’s medical practitioner or nurse practitioner and, when required, information from an orthotist, pedorthist, podiatrist, occupational therapist or physical therapist.

“Medically essential to achieve or maintain basic functionality” refers to a client’s need for orthoses due to an impairment which is necessary to perform their day-to-day activities in their home and/or community. 

Each orthosis request is reviewed on an individual basis and the client’s needs are taken into consideration. If the factors confirm that the item is medically essential to achieve or maintain basic functionality, and all other eligibility requirements have been met, the client is eligible for the requested item. 

Note: the information to be considered under each factor is not all-inclusive as it is important to preserve the discretion of the ministry decision maker and allow for flexibility to assess uncommon or unexpected circumstances.

When assessing the information provided to determine if the orthoses is medically essential to achieve or maintain basic functionality, the two factors to be considered are:

Factor 1: The client’s impairment

Information regarding the client’s impairment provides the medical basis for the item and the reason why it is being requested. The impairment may result from a number of different medical conditions that restrict the client’s functional ability.

When considering this factor, the following information is reviewed:
 

  • The diagnosis provided by the medical practitioner or nurse practitioner to assist in determining if it is reasonable to expect that there are functional limitations and whether the medical condition presented is likely to need orthoses.
  • The medical information provided to assist in determining the applicant’s level of functioning. This includes information regarding:
    • the reason for the orthosis request
    • how the client performs day-to-day activities in their home and/or community
    • whether the medical condition would deteriorate without the orthoses
    • physical skills or limitations (e.g., range of motion, ambulation, endurance, coordination and strength) in relation to the item requested 

Factor 2: The orthosis requested

The type of orthosis requested is reviewed to confirm that due to an impairment, the item is required for basic functionality. 

When considering this factor, the following information is reviewed:
 

  • Description of the item that is being requested. 
  • The type and condition of the client’s present orthosis (if applicable) to determine its appropriateness and why it is no longer meeting the needs of the client. This may indicate if repairs or modifications can be done to the existing item or if a replacement is needed.
  • The adaptability of the orthosis if the client’s functional status is likely to change, to determine if the item is sustainable in meeting their anticipated medical needs. For example, is the requested knee-ankle-foot orthosis able to accommodate future modifications such as specialized knee hinges?

Examples where a request may be considered medically essential to achieve or maintain basic functionality:
 

  • A client with a torn anterior cruciate ligament (ACL) is requesting a custom knee brace. The brace is prescribed by a medical practitioner and fitted by an orthotist. It is required to achieve walking ability to carry out basic activities such as grocery shopping, cooking and housekeeping.
  • A client with severe osteoarthritis is requesting an off-the-shelf wrist brace. The brace is prescribed by a medical practitioner and required to maintain joint motion so the client can carry out personal care and housekeeping.

Examples where a request may not be considered medically essential to achieve or maintain basic functionality:
 

  • A client with a torn anterior cruciate ligament (ACL) is requesting an off-the-shelf knee brace prescribed by a nurse practitioner. The brace is only for use in playing soccer. Sports are not considered “day-to-day activities.”
  • The client does not have a medical condition or impairment requiring orthoses but wants custom-made shoes.

Effective: October 1, 2012

The ministry may consider repairing or replacing orthoses due to the item being damaged, worn out, or not functioning.

Repairs may be considered if all of the following are met:
 

  • it is more economical to repair, rather than replace, the orthosis
  • the orthosis has not been damaged by misuse
  • if the orthosis was not previously provided by the ministry, all other eligibility requirements must be met (e.g., prescription)

Note: Repairs, including modifications, should be completed by an appropriate professional. For example, the professional who fitted the orthosis when it was first provided.

Replacement may be considered if all of the following are met:
 

  • it is more economical to replace, rather than repair, the orthosis
  • the orthosis has not been damaged by misuse
  • the time period, if any, set out in the table below has passed

Note: The replacement time period does not apply when an item is required due to changes in a person’s medical condition or growth.

Orthosis

Replacement Time Period

Custom-made Foot Orthotics

3 years

Off-the-shelf Foot Orthotics

As needed

Custom-made Footwear

1 year

Modification to Footwear

1 year

Off-the-shelf Orthopaedic Footwear

1 year

Off-the-shelf Footwear

1 year

Ankle Brace

2 years

Ankle-Foot Orthosis

2 years

Knee-Ankle-Foot Orthosis

2 years

Knee Brace

4 years

Hip Brace

2 years

Upper Extremity Brace

2 years

Cranial Helmet

2 years

Torso or Spine Brace

2 years

Foot Abduction Orthosis

As needed

Toe Orthosis

1 year

Procedures

Effective: April 1, 2010

Clients requesting medical equipment must first be determined to be eligible for general health supplements, including medical equipment. The following procedures must then be completed to assess eligibility for orthoses. [For procedures for other types of medical equipment, see Related Links – Medical Equipment – Hearing Aids and Medical Equipment and Devices.]

Persons who are not income assistance or disability assistance recipients but require medical equipment for a direct and imminent life-threatening health need must meet the eligibility criteria for Life-Threatening Health Needs before being assessed for eligibility for medical equipment and devices [see Related Links – Life-Threatening Health Needs].

The ministry is the payer of last resort and requires that all other available resources must first be considered before funding any requests. If there are other resources available, the individual is not eligible for medical equipment from the ministry. Co-funding may be considered when other resources cannot pay the entire cost [see Policy - No Other Resources].

Effective: August 2, 2011

The following procedures are to be used to determine eligibility for orthoses.

Requests for off-the-shelf orthoses under $100

EAW

1.

Confirm the client is eligible for general health supplements and has explored all other funding resources (for example, WorkSafeBC, ICBC, or Veterans Affairs Canada).  [see Policy]

 

2.

Ensure that the client has provided a written prescription with diagnosis from a medical practitioner or nurse practitioner.

 

3.

Ensure the client has provided a quote from a service provider.  A service provider may include a pharmacy, hospital, orthopaedic appliance supplier, or orthotics supplier.

 

4.

Refer to policy to determine if the requested item is an eligible item and to ensure that the information provided meets the eligibility criteria.

 

5.

If the eligibility criteria are met, provide payment using the Purchase Authorization on the Health Case.

 

6.

Note on the case the details of the request. Details include substantive reasons explaining what is requested and why the eligibility criteria are met (or not met). If the orthosis is approved, include the cost of the orthosis and the name of the service provider.

Note:  The prescription may contain more than one item and all the items in that prescription should be considered as one request.  Items in the prescription should not be processed as separate requests.  For example, if the prescription contained a custom-made orthotic with an off-the-shelf footwear and the cost of the footwear is below $100, then the full request with required documents should be forwarded to Health Assistance Branch (HAB).

Requests for off-the-shelf orthoses over $100

EAW

1.

Confirm the client is eligible for general health supplements and has explored all other funding resources (for example, WorkSafeBC, ICBC, or Veterans Affairs Canada).  [see Policy]

 

2.

Ensure that the client has provided a written prescription with diagnosis from a medical practitioner or nurse practitioner.

 

3.

Ensure the client has provided a quote from a service provider. A service provider may include a pharmacy, hospital, orthopaedic appliance supplier, or orthotics supplier.

 

4.

Refer to policy to determine if the requested item is an eligible item.

 

5.

Forward all documentation to Health Assistance Branch (HAB) for adjudication.

HAB

1.

Refer to policy and ensure that eligibility criteria are met.

 

2.

Determine if the Orthoses Request and Justification form (HR2894) needs to be completed.

 

3.

If approved, a letter will be issued to the client and a purchase authorization will be issued to the service provider. If denied, a letter and a decision summary outlining the reasons for the decision will be sent to the client.

 

4.

Note all details on the case. Details include substantive reasons explaining what is requested and why the eligibility criteria are met (or not met). If the orthosis is approved, include the cost of the orthosis and the name of the service provider.

Requests for all custom-made orthoses

EAW

1.

Confirm the client is eligible for general health supplements and has explored all other funding resources (for example WorkSafeBC, ICBC, or Veterans Affairs Canada).  [see Policy]

 

2.

Provide the client with the Orthoses Request and Justification form (HR2894) and complete Section One.

 

3.

Advise the client to take the HR2894 to their medical practitioner or nurse practitioner for completion of Section Two. The practitioner will then refer the client to a certified Orthotist, Pedorthist, Podiatrist, Occupational Therapist or Physical Therapist for completion of Section Three.

 

4.

Forward all information to HAB for adjudication.

HAB

1.

Confirm HR2894 is fully completed.

 

2.

Ensure the client has provided a quote from a service provider.

 

3.

Refer to policy and ensure that eligibility criteria are met.

 

4.

If approved, a letter will be issued to the client and a purchase authorization will be issued to the service provider. If denied, a letter and a decision summary outlining the reasons for the decision will be sent to the client.

 

5.

Note all details on the case. Details include substantive reasons explaining what is requested and why the eligibility criteria are met (or not met). If the orthosis is approved, include the cost of the orthosis and the name of the service provider.

Authorities and Responsibilities

Effective: August 2, 2011

Medical Equipment - Orthoses

Employment and Assistance Worker

 

  • Assessing eligibility for purchases of off-the-shelf orthoses under $100

    Note: all repairs are to be submitted to HAB
Health Assistance Branch (HAB)
  • Assessing eligibility for purchases and repairs of off-the-shelf orthoses over $100
  • Assessing eligibility for purchases and repairs of all custom-made orthoses
  • Assessing eligibility for all repairs
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