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Coverage limits are harsh reality for amputees

Politico.com, 4/23/13

AP Photo

Most private insurance plans have a cap on coverage for prosthetics. | AP Photo

By KATHRYN SMITH | 4/23/13 5:04 AM EDT

Those who lost limbs in the Boston Marathon bombings now need care to learn to navigate the world in a new way — and navigate a thorny area of health care coverage, too.

In the case of the Boston bombings, pledges and offers of support have poured in to help with the health care costs of the 14 people who reportedly lost all or part of a limb. But for some amputees, covering the staggering cost for prosthetics care can be a struggle.

Prosthetic limbs can range in cost from $5,000 to more than $50,000 for a more advanced leg device that starts above the knee, said Dan Ignaszewski, director of government relations at the Amputee Coalition of America, an advocacy and support organization.

A prosthetic device typically lasts about three to five years. Some people make them last longer, but others — especially growing children — need replacements more often.

But most private insurance plans have a cap on coverage for prosthetics, or durable medical equipment, Ignaszewski said — usually in the range of $2,500 to $5,000 a year.

Regular surveys of the Amputee Coalition’s members show “the No. 1 issue is affordable access to prosthetic care,” Ignaszewski said. “Most insurance plans that we find have some restrictions for cost on prosthetic care.”

And that’s not even accounting for the costs of rehab — which can take months, according to Dr. Simona Manasian, a rehabilitation medicine physician at Boston Medical Center, which treated five patients who underwent amputations after the bombings.

Manasian says the good news is that advanced technologies in prosthetics will make it possible for the amputees to resume most of their normal activity. But they’ll go through an extensive rehabilitation period that integrates psychological and social care to help process the loss of their limb.

For traumatic amputees, “the outcome is, in general, very good in regards of regaining function. It’s just a lengthy process,” Manasian said.

The Affordable Care Act means some will see improved coverage of prosthetic devices. Most states are including prosthetic coverage in the “rehabilitative and habilitative services and devices” essential health benefit, though not all states have explicitly included it in their essential health benefit packages, Manasian said.

And already at the state level, 20 states have enacted legislation to address insurance coverage of prosthetics, according to the coalition.

Nine of these states require that the coverage for artificial limbs matches what Medicare pays. They also won’t cover a replacement in less than a set period, usually around three to five years.

Eleven state laws — including Massachusetts’s — require that a plan’s prosthetics coverage standards be on par with or better than other covered benefits. These state laws also ensure there is no cap on the cost of prosthetics coverage.

Seventeen of these states require that plans regulated at the state level include prosthetics coverage. The other three — California, Utah and Virginia — just require that if plans do choose to provide coverage, it must be on par with the plan’s other services or that at least one plan offered by a company include adequate prosthetic coverage.

When it comes to the politics of passing a new law, prosthetics coverage for amputees tends to be an issue both parties can agree on. “In every state that [prosthetics legislation] has passed, it’s been passed with broad bipartisan support,” Ignaszewski said.

And the national attention given to the Boston Marathon bombings means that those who lost a limb that day will most likely get most of the financial help they need.

“It’s one of those things that — really in an instance like this — the last thing that somebody should have to worry about is whether they’ve got coverage for a prosthetic device,” Ignaszewski said.


Read more: http://www.politico.com/story/2013/04/boston-marathon-harsh-reality-for-amputees-90467.html#ixzz2RIvbqUMK

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