The bill amends title XIX of the Social Security Act to treat doctors of podiatric medicine (DPMs) as physicians for the purpose of Medicaid coverage of physician services. That change makes services delivered by podiatrists eligible for coverage under state Medicaid programs subject to federal Medicaid rules, with a general effective date of January 1, 2026 and a limited state legislative transition period.
The bill also revises Medicare’s statutory language for therapeutic shoes for people with diabetes (section 1861(s)(12)). It specifies the clinical findings a physician must document (examples include peripheral neuropathy and prior ulceration), requires attestation of a diabetes diagnosis and comprehensive plan of care, and requires fitting/furnishing by a physician or a Secretary-designated qualified individual (for example, a pedorthist or orthotist).
It adds these shoes to the list of items covered by a Stark exception. The Medicare provisions take effect January 1, 2028.
At a Glance
What It Does
The bill amends Medicaid law to include podiatric physicians in the definition of 'physician' eligible for Medicaid physician services, and revises Medicare’s therapeutic-shoe coverage criteria to require specific physician documentation and that shoes be fitted by qualified personnel. It also adds therapeutic shoes to a Stark Law exception.
Who It Affects
Primary stakeholders are Medicaid beneficiaries who need foot and ankle care, podiatrists billing Medicaid, Medicare beneficiaries eligible for therapeutic shoes, suppliers (pedorthists, orthotists, footwear manufacturers), and state Medicaid agencies that must implement the change under their state plans.
Why It Matters
The bill formalizes Medicaid coverage access for podiatrists nationwide (subject to state-plan mechanics), and clarifies Medicare documentation and furnishing rules that can change who may bill and what documentation is required for diabetic-shoe claims — both changes have implications for utilization, program spending, and compliance risk.
More articles like this one.
A weekly email with all the latest developments on this topic.
What This Bill Actually Does
The bill makes two discrete but related changes to federal health programs. First, it amends Medicaid’s coverage statute so that services provided by doctors of podiatric medicine count as physician services for title XIX billing.
Practically, that removes an ambiguity in some state plans about whether a DPM is a ‘‘physician’’ for Medicaid physician-service coverage and aims to ensure Medicaid enrollees can obtain covered foot-and-ankle care from podiatrists under their state plans.
Second, the bill rewrites the Medicare statutory provision that governs extra‑depth or custom‑molded therapeutic shoes for people with diabetes. Instead of the broader, less prescriptive language currently in law, the statute will require the treating ‘‘physician as defined in subsection (r)’’ to document objective clinical findings consistent with peripheral neuropathy or related risk (the text lists examples such as altered foot sensation, prior ulceration, deformity, prior lower‑extremity amputation, or poor circulation).
The physician must also attest that the patient has diabetes, is on a comprehensive plan of care for diabetes, and needs the shoes. The bill further requires that the shoes be fitted and furnished either by a physician or by another qualified individual — examples given are pedorthists or orthotists — with the Secretary of HHS setting the qualifications.A technical but consequential change adds these therapeutic shoes to one of the statutory exceptions to the physician self‑referral (Stark) prohibition.
That alters the compliance landscape for referrals and ownership arrangements involving those items. The bill staggers implementation: the Medicaid change generally applies to services furnished on or after January 1, 2026 (with a state‑law transition window where required), while the Medicare changes take effect for items and services furnished on or after January 1, 2028.Taken together, the measures aim to improve access to specialized foot care for people with diabetes by clarifying who qualifies as a Medicaid physician and by tightening Medicare’s documentation and furnishing rules for diabetic shoes — changes that will shift billing patterns, documentation workflows, and compliance requirements across providers and payers.
The Five Things You Need to Know
The bill amends 42 U.S.C. 1396d(a)(5)(A) to expand the Medicaid ‘‘physician’’ reference from just section 1861(r)(1) to paragraphs (1) and (3) of 1861(r), explicitly recognizing podiatric physicians for title XIX physician-service coverage.
Medicaid recognition takes effect for services on or after January 1, 2026, but states that need legislative changes get a transition period tied to the next regular state legislative session.
The bill rewrites 42 U.S.C. 1395x(s)(12) to require a physician to document peripheral neuropathy or listed risk findings, attest to a diabetes diagnosis and a comprehensive diabetes care plan, and attest that the patient needs therapeutic shoes.
It requires therapeutic shoes to be fitted and furnished by a physician or another Secretary‑designated qualified individual (the bill cites pedorthists and orthotists as examples).
The bill adds extra‑depth or custom‑molded therapeutic shoes to the list of items covered by a Stark Law exception (conforming amendment to 42 U.S.C. 1395nn(h)(6)), and the Medicare provisions apply to items furnished on or after January 1, 2028.
Section-by-Section Breakdown
Every bill we cover gets an analysis of its key sections.
Include podiatric physicians in Medicaid’s physician definition
This provision replaces the statutory reference to only paragraph (1) of 1861(r) with a reference to paragraphs (1) and (3). The practical effect is that services provided by podiatric physicians (DPMs), which are described in 1861(r)(3), qualify as physician services under Medicaid’s benefits statute. States must recognize those services as eligible for federal Medicaid financing when provided as physician services.
Effective date Jan 1, 2026, with state legislative transition window
The Medicaid change applies to services furnished on or after January 1, 2026. If a state needs a change to its laws to comply, the statute gives a safe harbor until the first calendar quarter after the close of the state’s next regular legislative session (with special rules for two‑year sessions). This preserves federal compliance status for state plans while giving legislatures time to amend statutes or regulations.
New clinical documentation and furnishing requirements for therapeutic diabetic shoes
The Medicare provision replaces the existing subsection with a tightly worded list of requirements. A treating physician as defined in 1861(r) must document specific clinical evidence of risk (peripheral neuropathy and related signs), attest to a diabetes diagnosis and that the patient is on a comprehensive plan of care, and attest that the shoes are needed. The provision also requires that shoes be fitted and furnished by a physician or another qualified individual—CMS must identify those qualifications—shifting responsibility for who may supply and bill for these items.
Adds therapeutic shoes to items eligible for a physician‑referral exception
The bill adds 'extra‑depth shoes with inserts or custom‑molded shoes with inserts' to the list of items under the physician self‑referral statute exception. That means certain ownership or compensation arrangements involving these shoes can qualify for an exception to the Stark prohibition, subject to the statutory and regulatory conditions that govern exceptions.
Medicare changes apply from January 1, 2028
All changes to Medicare—both the documentation/furnishing requirements and the Stark conforming edit—apply to items and services furnished on or after January 1, 2028. This delayed effective date allows Medicare administrators, suppliers, and clinicians time to adjust billing practices and for HHS to define the qualifications for non‑physician fitters.
This bill is one of many.
Codify tracks hundreds of bills on Healthcare across all five countries.
Explore Healthcare in Codify Search →Who Benefits and Who Bears the Cost
Every bill creates winners and losers. Here's who stands to gain and who bears the cost.
Who Benefits
- Medicaid beneficiaries with foot and ankle conditions: They gain clearer statutory entitlement to receive covered physician services from podiatrists under Medicaid, reducing coverage uncertainty and potentially expanding access to specialized foot care.
- Doctors of Podiatric Medicine (DPMs): The statutory change supports billing physician‑level services to Medicaid programs, which can expand patient panels and revenue streams where state plans adopt the change.
- Medicare beneficiaries with diabetes at risk of foot complications: The clarified documentation and furnishing standards aim to standardize who supplies therapeutic shoes and when Medicare will pay, which could improve consistency of care.
- Pedorthists and orthotists (and qualified footwear suppliers): By recognizing qualified non‑physician fitters in the statute and directing the Secretary to set qualifications, the bill creates a clearer role and potential billing pathway for these professionals.
Who Bears the Cost
- State Medicaid programs: Expanding the universe of covered physician services may raise utilization and program costs for states, at least initially, and states may need to amend statutes, provider enrollment rules, and provider manuals.
- Medicare (and possibly beneficiaries): The more prescriptive documentation and furnishing rules could increase administrative burden for clinicians and suppliers; if utilization rises, Medicare program spending could grow.
- Clinicians and suppliers (physicians, DPMs, pedorthists, orthotists, footwear vendors): They must change documentation and billing workflows to satisfy the new attestation and furnishing requirements and may face additional audit risk without clearer CMS guidance.
- HHS/CMS: The agency must issue guidance or regulations to define the qualifications for non‑physician fitters and operationalize coverage review and audit standards, requiring staff time and rulemaking resources.
Key Issues
The Core Tension
The central trade‑off is between improving access to specialized diabetic foot care (and thereby preventing costly complications) and expanding program exposure to higher utilization, administrative complexity, and potential billing risk; the bill clarifies who can provide and bill for services but pushes many critical implementation choices to states and to CMS rulemaking, where cost control and fraud‑prevention priorities may pull in the opposite direction from access goals.
The bill’s Medicaid change is statutory and nationwide, but implementation depends on state plan mechanics. While the federal statute now treats DPMs as physicians for title XIX, state Medicaid program rules, provider enrollment processes, and state scope‑of‑practice laws still control day‑to‑day access and payment.
States that need legislative changes get a transition delay, but that also means variable timing across states — some beneficiaries will see immediate changes while others wait for state action.
On the Medicare side, the bill tightens documentation by listing clinical findings and specified attestations, but it leaves several operational questions unresolved. The Secretary must define who qualifies as a ‘‘qualified individual’’ to fit and furnish shoes; absent clear CMS regulations or program guidance, suppliers and clinicians will face uncertainty about billing privileges.
The statutory list of clinical signs may help standardize coverage, but it could also spawn narrower interpretations in audits: claims could be denied on semantic grounds if documentation does not mirror the statutory language exactly. Finally, adding therapeutic shoes to a Stark exception reduces one barrier to certain referral arrangements but does not eliminate other fraud and abuse constraints; providers relying on ownership or compensation arrangements will still need to ensure full compliance with exception conditions and supporting documentation.
Try it yourself.
Ask a question in plain English, or pick a topic below. Results in seconds.