Who's Paying for Tarver's Leg?
By Daniel Gurley, AOPA Government Affairs Department

The news article shows a photo of a young man wearing a T-shirt that proudly displays the message “This Shirt Bought Tarver a Leg.” 

It goes on to explain that Tarver Hannant, the man in the photo, lives in Portland, Oregon and lost his leg after an electrocution accident on his 14th birthday. Since that time, he has discovered something most Americans never know: medical insurance companies frequently place caps on expenditures for prosthetic devices. 

In Hannant’s case, his insurance only provides a maximum of $5,000 in coverage, well below the amount necessary for his prosthetic leg. So he’s selling T-shirts for $25 each to raise the necessary money. 

Hannant recently got some good news. Oregon recently passed equal treatment legislation, a type of parity bill, for prosthetic devices. In the future, Hannant can concentrate on living his life, instead of struggling to pay for his necessary prosthesis. 

The benefits of parity
Insurance coverage for prosthetic limbs and orthotic braces has steadily become more problematic. Presently many of those who have suffered limb loss, or those who need orthoses, have insufficient insurance coverage to obtain necessary care. 

To combat this problem, many states are implementing legislative solutions. However, only seven of these states have passed legislation requiring orthotic and prosthetic coverage. According to the Amputee Coalition of America, 22 additional states are advancing legislation.

There are two types of orthotic and prosthetic parity bills: 

• Mandated coverage, which requires insurance companies to provide coverage for orthotic and prosthetic devices. 
• Equal treatment, which requires insurance companies to cover orthotic and prosthetic devices in the same manner as other covered treatment like medical/surgical care. Equal treatment means that an insurance company cannot discriminate toward amputees seeking prosthetic limbs by only allowing them one per lifetime, or having a cap on the amount the company will pay towards the device in a year or a lifetime. It would also cover orthotic devices in the same manner it covers other treatment items. 

The ideal scenario is for states to pass both mandated coverage and equal treatment. This would guarantee that both orthoses and prostheses would be covered services and that they could not be discriminated against by varying levels of coverage.

While AOPA, along with others in the profession, strongly supports both orthotic and prosthetic parity, it is usually easier to achieve parity for prosthetic devices. The hope is once the door is open for prosthetic parity, orthotic parity can be achieved at a later date.

Many organizations have supported parity legislation in the states, as well as pushing for federal legislation. A group working towards parity in all states is the Amputee Coalition of America. Their Web site contains information on the progress of parity legislation in all the states. AOPA, NCOPE, AAOP, and Department of Veterans Affairs are just a few of the other organizations that publicly support parity.

The cost perception problem
If so many organizations are supporting parity, why do so many states lack it?

The simple answer is money. People assume that increasing insurance coverage means the amount they have to pay for insurance will go up. Some insurance companies want people to believe that this increase would be excessive.

No one wants to see health care costs exceed the amount that an average customer can pay. But a study of prosthetic parity by the California Benefits Review Program determined that the estimated cost to each member to institute comprehensive coverage for prosthetics would be 16 cents per month. The Colorado Department of Health Policy and Financing found that prosthetic coverage would increase members’ out-of-pocket costs by 12 cents per member per month.

What opponents don’t want to discuss is the amount of money amputees who are not fitted with prosthetic devices cost the health care system. If amputees are prevented from accessing the care needed to continue to be productive members of society, they are forced to become reliant on public programs such as Medicaid.

Complications such as flexion contractures, skin breakdown, osteoporosis, muscle loss, depression, and costs for nursing home or home care can all far exceed the costs of providing prosthetic care to patients.

Savings also come from unemployment insurance, state employment and training programs, rehabilitation and counseling programs. In a fact sheet available on their Web site, the Amputee Coalition of America states that “every dollar spent on rehabilitation, including prosthetic care, saves more than $11 in disability insurance.”

Parity and your practice
Why should providers be interested in parity legislation? The answer is simple, yet poignant. Orthotic and prosthetic parity bills ensure that patients like Tarver Hannant have access to medically necessary care with qualified providers.

Get Involved

To get directly involved in parity efforts, contact the Amputee Coalition of America at (888) 267-5669 or www.amputee-coalition.org.

In turn, practitioners can administer care without unreasonable budgetary constraints. The practitioner has more time to develop a care plan and see the patient through the entire process. Adequate insurance allows the provider to see the patient in follow-up visits to ensure appropriate fit and safety. Parity for orthotic and prosthetic devices would simply make your practice better.

AOPA strongly supports all efforts for parity legislation and will be working to support parity efforts—because this is a policy that could really benefit your practice.

Daniel Gurley is manager of regulatory affairs of AOPA’s Government Affairs department. Questions? Contact him at (571) 431-0812 or dgurley@AOPAnet.org.