The Medicare O&P Patient-Centered Care Act (H.R. 4475, S. 2329)

Timely access to reasonable and necessary orthotic and prosthetic (“O&P”) care is critically important to ensure that Medicare beneficiaries with limb loss and limb difference in need of orthotic braces and prosthetic limbs maintain and improve their health and live as independently as possible.  O&P clinical care is a combination of clinical services that culminate in the provision of an orthosis or prosthesis that satisfies the unique needs of each patient. Clinical care is necessary to ensure the fit and function of all limb prostheses and custom orthoses.

Appropriate O&P care supports a functional, active lifestyle. The Medicare Orthotics and Prosthetics Patient-Centered Care Act would ensure beneficiary access to patient-centered clinical O&P care through the following improvements to the Medicare program.  The legislation would ensure:

• Patient Protection from Fraud and Abuse: Prohibit the practice of “drop shipping” custom fitted and fabricated orthoses and all prostheses to Medicare beneficiaries. Under this provision, only off-the-shelf (OTS) orthoses would be allowed to be drop shipped to the patient’s home without any clinical intervention by a provider or supplier. This prohibition would prevent unscrupulous suppliers, who rely on “lead generators” that operate through a model based on late-night advertisements and telemedicine companies, from shipping custom fitted and fabricated orthoses and all prostheses to Medicare beneficiaries without providing necessary clinical care.
• Access to O&P Care from Quality Providers: Ensure that patients have access to the full range of orthotic care from their primary O&P practitioner rather than requiring patients to visit multiple providers in the case where the treating orthotist or prosthetist does not have a competitive bidding contract. This provision helps ensure efficient and convenient patient care and would treat O&P practitioners similarly to physicians and other practitioners as defined by the Secretary. Since O&P practitioners would be reimbursed according to the adjusted Medicare fee schedule established through the competitive bidding process for OTS orthoses, this provision should not cost the Medicare program any more than it will otherwise spend on OTS orthoses. 
• Patient Access to Appropriate O&P Care as their Needs Evolve: Ensure that Medicare beneficiaries have access to custom-fitted and custom-fabricated orthoses when a replacement is necessary due to a change in their condition or clinical needs, an irreparable change in the condition of the orthosis, or excessive cost of repairs. Currently, Medicare restricts the replacement of orthoses during the “reasonable useful lifetime” of the orthosis.  These restrictions currently force Medicare beneficiaries to wait for a period of time, often five years, before they are eligible for Medicare coverage of a replacement orthosis.  Section 428 of the Benefit Improvement and Protection Act of 2000 provides for an exception to continuous use and useful lifetime restrictions for prosthetic devices if an ordering physician determines that replacement device is medically necessary for certain reasons.  This provision would extend the exception to custom-fitted and custom-fabricated orthotic devices.

Please take a few moments to contact your legislators and ask them to support the Medicare Orthotics and Prosthetics Patient-Centered Care Act. The more we make our voices heard, the more likely we are to create positive change.

If you have any questions, contact Joe McTernan, Director of Health Policy and Advocacy at jmcternan@AOPAnet.org.