Health Insurers Found Limiting Coverage of Prosthetic Limbs
On January 6, KFF Health News’ Michelle Andrews reported on coverage limitations for prosthetic limbs. Health insurers may deny coverage for these devices by claiming they aren’t medically necessary or are experimental.
An estimated 2.3 million people are living with limb loss in the U.S., according to an analysis by Avalere, a healthcare consulting company, Andrews writes. That number is expected to as much as double in the coming years as people age and a growing number lose limbs to diabetes, trauma, and other medical problems. According to a report by the AHRQ, the federal Agency for Healthcare Research and Quality, fewer than half of people with limb loss have been prescribed a prosthesis.
“Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it,” said Jeffrey Cain, a family physician and former chair of the board of the Amputee Coalition, an advocacy group.
AHIP, a trade group for health plans, notes that plans generally provide coverage when the prosthetic is medically necessary, such as replacing a body part or functioning for walking and day-to-day activities. However, Ashlie White, chief strategy and programs officer at the Amputee Coalition mentions that insurance companies often cap devices and restrict the types of devices approved.
Andrews reports that a 2000 Colorado law requires insurers to cover prosthetic arms and legs at parity with Medicare, which requires coverage with a 20 percent coinsurance payment. About half of the states have passed “insurance fairness” laws requiring prosthetic coverage on par with other covered medical services in a plan that enables people to do sports. However, these laws apply only to plans regulated by the state. Over half of people with private coverage are in plans not governed by state law.
The Medicare program’s 80-percent level of coverage of prosthetic limbs mirrors its coverage for other services. However, the Government Accountability Office found that only 30 percent of beneficiaries who lost a limb in 2016 received a prosthesis in the following three years.
