Saturday, December 31, 2011

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.

10 comments:

  1. You should post this in the AMPS group on FB. There may be others who are facing this same issue.

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    Replies
    1. Indeed there are. I too am a BK (Below the knee) amputee who has now run into the same BS at Kaiser. In my 32 years of being an amputee, I have never been turned down for prosthetic coverage till now. Captain Pegleg, thanks for posting this. Its been very helpful. Captain, my Captain!

      Marc "PeglegSatan" Hochman

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  2. when dealing with health insurance denying your claims it is best to get an attorney who has experience with this kind of crap. Not only he should know how to speed up the process, by writing proper threatening letters, but he will happily take to court your insurance company and the insurance broker - to re-pay you the cost of hiring a lawyer, for having to take them to court and for the pain and suffering plus damages for wilfully disregarding the law. And should it happen that they denied someone like you before on purpose, you would in position to go after them in a class action lawsuit and get quite rich in the end.

    Jurrors love to hear about a giant greedy corporation screwing a poor needy plaintiff...

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  3. I am an amputee and also a certified prosthetist in Indiana. We DO have a parity law that passed about 4 years ago. In the past 4 years, I have only seen things getting worse, and not better. Since I am a small business owner, I have to carry an individual family policy. I am in great health, non-smoker, no blood pressure issues, etc. I have never had any problem changing insurance companies in my life (I have dealt with my own individual policies now for 13 years, and have been an amputee for 14 years).

    Since this parity law is in place, now the insurance comapanies ask right up front: "Are you pregnant, are you diabetic, have you been diagnosed with cancer, or any other disease or condition you are currently being treated for....ARE YOU AN AMPUTEE OR USE A PROSTHETIC LIMB?" If you answer "yes" to any of these questions, they will not take your application.

    Also, the National Federation of Independent Businesses (NFIB...which I am a member) has connections with an insurance company, and is supposed to be a connection to get cheaper rates and is basically set up to help the small business owners. When I called them, they asked me what state I was in, and told me there is a list of states that their carrier will not cover amputees. Their list of states is the same list which have parity laws in place.

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  4. Even in Indiana, I have seen 2 patients this past year who have individual family policies, and they have annual caps (one is $4000 per year, and the other was $5000 per year) for prosthetic devices. According to Indiana Parity laws, this is NOT allowed!!! But, after many conversations with the Indiana Department of Insurance (IDOI), they have NO authority or power to make any company comply with this parity law. They can "investigate" and they can "write a letter of compliance" to an insurance company....but they cannot just go to some insurance company and arrest someone for violating some insurance laws. There really is NOTHING they can do to help these amputees out.

    There is a national effort to have a nationwide prosthetic parity law put in place, but based on what I have seen happen in my own state with parity laws, I cannot see how a national parity law would help any amputees.

    And, another issue that ALL amputees should be aware of, is with the new Obamacare coming into full effect on Jan 1, 2014 (unless it is repealed or has some MAJOR changes), prosthetics and orthotics is NOT a covered benefit under this wonderful healthcare reform.

    YES!!! That is the situation!! I have read most of the 2000+ pages of the legislation, and in the PDF format, you can use the search engine and type in "prosthetic" and see there are 5 "hits" for this word. They are all related to the accreditation of providers (generally aimed at pharmacies) and related to surety bonds. But unlike the congressional bill where prosthetics were "covered as currently outlined in the current CMS benefits and rules" (it was very plainly mentioned and covered), this NEW healthcare that passed and was signed into law, does NOT mention it as "covered", and so therefore it is NOT COVERED!!

    So all the parity laws in the country are totally useless if prosthetics are NOT covered under the new healthcare laws and mandates. Even if the law states that every insurance company must pay for prosthetics, but the national laws state that they are NOT covered benefits, then they are NOT covered!

    This is an issue that some of the organizations representing prosthetics are working on, and are aware of. But, it seems that many of the industry "leaders" are so far liberal and love everything and anything that Pres. Obama says or does, they really cannot work too hard to bring any negative publicity to the Obamacare issue....even if that means that amputees will not have access to prosthetics under their insurance coverage. These leaders are good people, and I am sure have good intentions and all, but I really struggle with how they can be there really supporting the amputees and the field of prosthetics, while still defending and praising Pres. Obama and this healthcare reform.

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  5. I am a physician working with a patient who is in the exact same situation that you were with regard to your prosthetic. It has been denied twice by kaiser. This is not my patient but I am involved in trying to solve this issue and I am working with an investigative reporter. I would love to talk to you for some guidance so I can focus my fight. Please email me at jonathan.r@roadrunner.com.

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  6. I think your post is of importance for other amputees. Will you consider cross-posting it in our community? If you agree, please register and we'll grant you an author permission.
    Thanks and all the best,
    Ofri.
    http://www.amputee-life.org

    ReplyDelete
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  8. This comment has been removed by the author.

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  9. I am really happy to hear that they gave you good coverage for prosthetics. If it is not for the complaint you sent to Department of Managed Health Care it would have took you more time before they upgraded your plan.

    In general, it's always very important to find a good insurance company who will stand by you during times like these. Regardless of if you're in need of health insurance, home insurance, car insurance, or life insurance, making the best decision about which insurance company you work with is crucial.

    For my personal insurance needs I have been very fortunate to find Marchionne Insurance. They have great coverage and quotes, especially in my local area of Stoneham MA. Anyone who is looking for car or home insurance in Stoneham I would definitely recommend requesting a quote from them! Simply the best when it comes to comprehensive insurance policies and one-on-one attention.

    - Ash

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