When Michael Adams was researching health insurance options for 2023, he had a very specific request: coverage for prosthetics.
Adams, 51, lost his right leg to cancer 40 years ago and has lost countless legs to wear and tear. He chose a gold plan on the Colorado Health Insurance Marketplace, which covered prosthetics, including a microprocessor-controlled knee, like the one he had used for years. This feature increases stability and helps prevent falls.
But when his leg needed to be replaced last January after about five years of daily use, his New Market health plan didn't approve it. The insurance company said the leg with an electronically controlled knee, which costs about $50,000, is not medically necessary, even though Colorado law leaves that decision up to the patient's doctor and begins with his employer. , who has been prescribing versions of that leg for years.
“The electronic prosthetic knee is life-changing,” said Adams, who lives in Lafayette, Colorado, with his wife and two children. Without it, “it's like going back to being a kid and having a wooden leg.” A microprocessor in the knee reacts to different surfaces and inclines, changing the state of the art if it detects movement that indicates a user has fallen. Gotta be stiff.
People who need surgery to replace a joint typically don't face similar barriers to coverage. According to the federal Agency for Healthcare Research and Quality (AHRQ), 1.5 million knee or hip replacement surgeries were performed in U.S. hospitals and hospital-owned outpatient facilities in 2021. The median price for an uncomplicated total hip or knee replacement at top orthopedic hospitals in 2020 was just over $68,000, according to one analysis, although health plans often negotiate lower prices.
Coverage Differences Between Plans
For people in the amputee community, the difference in coverage amounts to discrimination.
“If the knee replacement is covered by skin, insurance will cover it, but if it's covered by plastic, insurance won't cover it,” said Jeffrey Cain, a family physician and former chairman of the board of directors of the advocacy group Amputee Alliance. .Kane wears two prosthetic legs, which he lost in a plane accident nearly 30 years ago.
Health plans typically provide coverage when they determine a prosthetic is medically necessary, such as to replace a body part or function for walking and daily activities, according to AHIP, the health plan trade group. However, in practice, prosthetic coverage among private health plans varies widely, said Ashley White, chief strategy and projects officer for the Amputee Alliance. While coverage for basic prosthetics may be included in a plan, “insurers often place caps on devices and limit the types of devices approved,” White said.
An estimated 2.3 million people in the United States live with limb loss, according to an analysis by healthcare consulting firm Avalere. This number is expected to double in the coming years as we age and more people lose limbs due to diabetes, trauma and other medical problems.
According to a report by AHRQ, less than half of people with limb loss have prosthetics. Although microprocessor-controlled knees like the Adams have been used for decades, plans may deny coverage for the prostheses, claiming they are not medically necessary or are merely experimental devices.
“Insurance Fairness” Act
Kane was instrumental in the passage of a 2000 Colorado law that required insurance companies to provide coverage for prosthetics and limbs on par with Medicare, which required a 20 percent coinsurance. Since the measure was enacted, about half of the states have passed “insurance equity” laws requiring coverage for prosthetics to be the same as other covered medical services in the plan, or requiring coverage for prosthetics that enable people to play sports. But these laws only apply to state-regulated programs. More than half of people with private insurance are in plans that are not governed by state law.
The Medicare program covers 80% of prosthetics, which reflects its coverage of other services. Still, an October Government Accountability Office report found that only 30 percent of beneficiaries who lost a limb in 2016 received a prosthetic limb within the next three years.
Cost is a factor that many people consider.
“Regardless of coverage, most people have to pay for the device,” White said. As a result, “many people will set up payment plans for their devices,” she said. Some people may apply for a loan.
The federal Consumer Financial Protection Bureau has proposed a rule that Lender repossession prohibited If people are unable to repay their loans, medical equipment such as wheelchairs and prosthetics are available.
“This is a replacement limb,” said White, whose organization has heard of several cases where lenders have repossessed wheelchairs or prosthetic limbs. Revocation “is effectively a personal punishment”.
Adams ended up owing about $4,000 in coinsurance for his new leg, which reflected his share of the rate the insurance company negotiated for the knee and foot portion of the leg, but not the fit for his stump expensive part that does not need to be replaced. Adams said the insurance company approved the prosthesis after an appeal, claiming an administrative error was made.
“We're lucky that we can afford the 20 percent,” said Adams, a self-employed leadership consultant.
Leah Kaplan doesn't have that kind of financial flexibility. She was born without a left hand and had a prosthetic until a few years ago.
Growing up, “I didn't want more reasons to be noticed,” Kaplan, 32, said of his decision not to use prosthetics. A few years ago, the cyclist got a prosthetic hand designed specifically for her bike. The device was included in a wellness program she developed through her work in Spokane County Government in Washington state to help people with developmental disabilities transition from school to work.
But when she tried to get approval to use the prosthetic hand for daily activities, her health plan turned her down. The myoelectric hand she requested would respond to electrical pulses on her arm, moving the hand to perform certain actions. Without insurance, the hand would have cost her more than $46,000, which she said she couldn't afford.
She worked with doctors and appealed to her insurance company, but was denied three times. Kaplan said she's still not sure what the specific rationale was, other than that the insurance company questioned the medical necessity of the prosthetic hand. The next step is to appeal to an independent review agency certified by the Office of the State Insurance Commissioner.
Kaplan said prosthetic hands are not a luxury item. The prosthetics clinic has ordered the hand and made a custom socket to fit the end of her arm. But she can't use it until coverage is determined.
At this point she felt defeated. “I've been waiting for this moment for a long time,” Kaplan said.
