Prosthetic "Parity" in California Has a Long Way to Go

In the fall of 2010, I was starting to have a lot of problems with my stump, skin irritation leading to scarring and an eventual minor surgery to remove scar tissue.  During this time, my employer changed insurance providers, and I was introduced to the OG of managed health care:  Kaiser Permanente.  My new docs referred me to the Kaiser prosthetic clinic, and I thought all was well.

Then, I got a phone call.  The amputee clinic scheduler couldn't schedule me.  Why?  I didn't have coverage for prosthetics.  "Now," I thought, "that can't be right.  I've been assured that California had prosthetic parity laws."  Well.... kinda.  California's Health and Safety Code Section 1367.18 reads, in part:

(a) Every health care service plan, except a specialized
health care service plan, that covers hospital, medical, or surgical
expenses on a group basis shall offer coverage for orthotic and
prosthetic devices and services under the terms and conditions that
may be agreed upon between the group subscriber and the plan. Every
plan shall communicate the availability of that coverage to all group
contractholders and to all prospective group contractholders with
whom they are negotiating. Any coverage for prosthetic devices shall
include original and replacement devices, as prescribed by a
physician and surgeon or doctor of podiatric medicine acting within
the scope of his or her license.

So they have to cover prostheses... if you opt for the coverage.  So obviously my first thought was that my boss opted to not buy the coverage, and I was quite upset.  Of course, this was not the case; the broker who sold the plan never offered it, in direct violation of the law.  Should be an easy fix, right?  Appeal the denial, point out the error, and they'll fix it.  Well, not quite.

After the denial, I sent a letter to KP's Member Case Resolution Center, quoted the relevant section, and demanded coverage.  After a second denial, I filed a complaint with the Department of Managed Health Care, which regulates HMOs in California.  It seems I was the first person to make a complaint with regard to this law, so what was supposed to be a two-week review process stretched to nearly three exhausting, infuriating months.

In the end, the DMHC saw things my way.  Kaiser upgraded me to a plan that included coverage for prothetics.  Of course, it took them another three or four months to approve the new socket I needed, but at least I finally won.

The lesson, of course, is that prosthetic parity laws are often not all  they're cracked up to be.  Limbs are not a luxury item, and we all--amputees and not--need to keep working to improve them.  And be prepared to fight for what you need from any insurer.  They're all evil.