When Michael Adams was researching health insurance options last year, he had a very specific requirement: coverage of prosthetic limbs.
Adams, 51, lost his right leg to cancer 40 years ago, and he’s worn out more legs than he can count. He chose a plan for gold on the Colorado Health Insurance Marketplace which covered prosthetics, including microprocessor-controlled knees like the one he has used for many years. This feature adds stability and helps prevent falls.
But when her leg needed to be replaced in January after about five years of daily use, her new marketplace health plan didn’t allow it. The electronically controlled leg, worth about $50,000, was not medically necessary, the insurer said, even though Colorado law leaves that decision up to the patient’s doctor, and he has been prescribing a version of that leg for many years, going back to when he had employer-sponsored coverage.
“The electronic knee prosthesis is life-changing,” said Adams, who lives in Lafayette, Colorado, with his wife and two children. Without it, “it would be like having a wooden leg again like when I was a child.” The microprocessor located in the knee reacts to different surfaces and inclinations, stiffening if it detects movement indicating a fall of its user.
Alana Adams
People who need surgery to replace a joint generally don’t face similar barriers to coverage. In 2021, 1.5 million knee or hip replacements were performed in U.S. hospitals and hospital-owned outpatient facilities, according to the federal Agency for Healthcare Research and Quality, or AHRQ . THE median price for an uncomplicated total hip or knee replacement at top orthopedic hospitals was just over $68,000 in 2020, according to one analysis, although health plans often negotiate lower rates.
For members of the amputee community, the disparity in coverage amounts to discrimination.
“Insurance covers a knee replacement if it’s covered in skin, but if it’s covered in plastic, they won’t cover it,” said Jeffrey Cain, a family physician and former chairman of the board of directors of the Ampute Coalition, an advocacy group. Cain wears two prosthetic legs, having lost his after a plane crash nearly 30 years ago.
AHIP, a trade group for health plans, said health plans generally provide coverage when the prosthesis is deemed medically necessary, such as to replace a body part or function for walking and daily activities. In practice, however, coverage of prosthetics by private health plans varies widely, said Ashlie White, head of strategy and programs at the Ampute Coalition. Although coverage for basic prosthetics may be included in a plan, “often insurance companies place caps on devices and restrictions on the types of devices approved,” White said.
This means that patient costs can also fluctuate widely, depending on the specifics of that individual’s coverage, plan restrictions, and even geographic differences in costs.
A estimated at 2.3 million people are living with limb loss in the United States, according to an analysis by Avalere, a health care consulting firm. This number should as much as double in the coming years, as people age and more people lose limbs to diabetes, trauma and other medical problems.
Less than half of people who have lost a limb have been prescribed a prosthesis, according to a study. AHRQ report. Plans can deny coverage for prosthetic limbs by claiming they are not medically necessary or that they are experimental devices, even though microprocessor-controlled knees like Adams’ have been used for decades.
Cain was instrumental in passing a 2000 Colorado law that required insurers to cover prosthetic arms and legs on par with Medicare, which requires coverage with a 20 percent coinsurance payment. Since this measure was signed into law, about half of states have passed “insurance fairness” laws that require coverage for prosthetics on par with other medical services covered in a plan or laws that require coverage of prostheses allowing people to play sports. But these laws only applies to diets regulated by the state. More than half of people with private coverage participate in plans not governed by state law.
The Medicare program’s 80% coverage of prosthetic limbs reflects its coverage for other services. However, an October report from Government Accountability Office found that only 30% of beneficiaries who lost a limb in 2016 received a prosthesis in the following three years.
Cost is a factor for many people.
“No matter what your coverage is, most people have to pay something for this device,” White said. As a result, “many people will benefit from a payment plan for their device,” she said. Some can take out loans.
The federal Consumer Financial Protection Bureau has proposed a rule that prohibit lenders from repossessing medical devices such as wheelchairs and prosthetics if people cannot repay their loans.
“This is a replacement limb,” said White, whose organization has heard of several cases in which lenders have repossessed wheelchairs or prosthetic limbs. Repossession is “literally a punishment inflicted on the individual.”
Adams ultimately owed a coinsurance payment of about $4,000 for his new leg, which reflected his share of the insurer’s negotiated rate for the knee and foot portion of the leg, but did not include the costly portion that fits around his stump, which didn’t need it. replacement. The insurer approved the prosthetic leg on appeal, saying it made an administrative error, Adams said.
“We’re fortunate to be able to afford that 20 percent,” said Adams, an independent leadership consultant.
Again, out-of-pocket costs – even if the patient has health insurance and a doctor’s prescription – can be prohibitive due to the plan’s coinsurance requirements as well as coverage caps or other limitations .
Leah Kaplan doesn’t have that financial flexibility. Born without a left hand, she did not have a prosthesis until a few years ago.
Growing up, “I didn’t want people to look at other reasons,” Kaplan, 32, said of her decision not to use a prosthetic. A few years ago, this cycling enthusiast acquired a prosthetic hand specially designed for use with her bike. That device was covered by the health plan she has through her job in Spokane County, Washington government, helping people with developmental disabilities transition from school to work.
But when she tried to get approval for a prosthetic hand to use for daily activities, her health plan turned her down. THE myoelectric hand she asked for would respond to electrical impulses in his arm that would move the hand to perform certain actions. Without insurance coverage, the hand would cost her just over $46,000, which she says she can’t afford.
Working with her doctor, she appealed the decision to her insurer and her request was denied three times. Kaplan said she still doesn’t know exactly what the rationale is, except that the insurer questioned the medical necessity of the prosthetic hand. The next step is to file an appeal with an independent reviewing organization certified by the state insurance commissioner’s office.
A prosthetic hand is not a luxury device, Kaplan said. The prosthetic clinic ordered the hand and made the custom socket that will fit the end of his arm. But until the insurance cover is sorted out, she cannot use it.
At this point, she feels defeated. “I’ve been waiting for this for so long,” Kaplan said.
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