Most of New York's health insurance exchange plans now cover only one external prosthetic device per limb per lifetime for adult amputees, making its coverage among the most restrictive in the country.
And that's what a Long Island amputee is trying to change with an online campaign.
Daniel Bastian, 49, of Massapequa lost his leg above the knee to cancer in 1989. Ten years later he co-founded Progressive Orthotics and Prosthetics in Albertson, which makes and repairs prostheses. Last year he began to notice that insurers -- unlike in years past -- were turning down many of his clients for reimbursements.
Bastian soon discovered why: Under the Affordable Care Act, states had to provide "benchmark" plans that determined the specifics of essential health benefits required of every ACA health plan sold in the state. New York chose Oxford EPO, which limited coverage to one external prosthetic device per limb per lifetime for adults. (Children are allowed replacements as they grow.)
Required to cover less, most insurers on the exchange have opted to do so.
The state Department of Health said that exchange plans have the option to provide more than the one prosthetic per limb per lifetime minimum.
"This limit is not unusual in plans both on and off of the marketplace, and this marketplace benefit was modeled after small business plans with the highest enrollments," a health department spokesman said in a statement.
But in fact, only two plans on the exchange offer more than the minimum, according to the health department: BlueShield of Northeastern New York, offered in the Albany area, and BlueCross BlueShield of Western New York, offered in the Buffalo area.
Leslie Moran, senior vice president of the New York Health Plan Association, a trade group for health insurance companies, said in an email that "this is a tough issue and plans are pretty much caught between the proverbial rock and a hard place."
Plans must keep within the actuarial value -- or the percentage of total average costs for covered benefits -- set by the ACA, and, she said, "the expenses associated with prosthetics can easily affect the AV [actuarial value] of a plan." In addition, plans' premiums are regulated by the state.
"The past two years, the majority of plans have had their premiums requests reduced, significantly in many cases," she said. "Without adequate rates from the state, plans are struggling to offer coverage with benefits as currently required, let alone expand the level of coverage."
Limit was once uncommon
That was not the case two years ago.
"Before the creation of the New York State exchange, I and other prosthetists in New York encountered only one health insurance plan with the one-limb/life restriction: Oxford," Bastian said. "That was true for more than a decade. And with Oxford, it was only their EPO plan that had this restriction."
Thaddeus E. Drygas, owner of Care Crafters Prosthetics and Orthotics in Nanuet in Rockland County and director of the business committee of the New York State Chapter of American Academy of Orthotists and Prosthetists, concurred: Before the ACA, only Oxford was so restrictive.
Said Dan Ignaszewski, director of government relations and marketing at the Amputee Coalition in Manassas, Virginia: "The one-limb-per-lifetime minimum was uncommon nationwide and in New York."
"There is no possible way a prosthesis can last a lifetime," Bastian said. "It's hard enough living a life with limb loss -- and then to find out you can't receive the devices you need to live an active life is devastating."
Prosthetics generally last three to five years and can cost from $5,000 to $80,000, Bastian said. From 1997 to 2012, 152,904 amputations were done in New York, 91 percent of them on people 45 and older, 60 percent of which were covered by Medicare, according to the Amputee Coalition.
Ignaszewski said New York's minimum coverage is among the worst in the country. Utah, Alaska and Puerto Rico are more restrictive, offering no coverage at all, according to the coalition. Nevada places a limit of $10,000 per lifetime per member.
"Arms and legs are not a luxury," he said. "No one is trying to take advantage of this benefit."
New York's minimum is also less than what both Medicare and the state's Medicaid program -- health insurance for low-income residents -- offer: They cover prosthetics based on medical necessity.
Seeking to rectify this, Bastian on March 4 launched a petition, at onelimbforlife.com, which has more than 11,500 signatures so far. And he has met with dozens of state legislators to change the minimum coverage to cover prosthetics when medically necessary.
Two bills have been introduced in the Assembly and State Senate, both of them calling for changing coverage to be "equal to or above Medicare's standard of coverage," and both have been referred to their respective insurance committees. The bill's Assembly sponsor, Aileen Gunther (D-Middletown), called the minimum "disheartening."
"It's denying people good health and costing taxpayers a lot more money. If you can't get a prosthetic, you can't work," Gunther said.
Sen. John Bonacic (R-Mount Hope), the bill's Senate sponsor, said, "This legislation would ensure that those who require the use of artificial limbs would not be burdened with the whole cost."
Lawyer: Plans 'repugnant'
That's something that Davor Floricic, 49, a construction company owner from Roslyn, knows firsthand. He lost a leg below the knee two years ago in a motorcycle accident. Over time, the limb has shrunk and he needs a new prosthesis. His Oxford health plan refused to cover the replacement, which he estimated cost about $20,000.
"It doesn't make any sense," Floricic said. "I do need to walk."
John D. Kemp, 65, of Roslyn was born with four missing limbs. President of The Viscardi Center in Albertson, which works with children and adults with disabilities, he likens the state's restrictions to "a disability tax."
"I need at least annual repairs for every one of my four limbs," he said. So far he has been paying out of pocket.
Kemp, a lawyer, said he is exploring the possibility of filing a class-action suit, charging disability and age discrimination if the state doesn't change the minimum. "On its face, it's so repugnant," he said.
Peter Thomas, 51, general counsel for the National Association for the Advancement of Orthotics and Prosthetics, lost both legs below the knee at age 10 in a car accident when he was growing up in Northport. Thomas, who said he has had 13 sets of limbs over his lifetime, said he would help with any lawsuit.
"This is clearly one of the most egregious coverage policies in the country," he said. "New York holds a dubious distinction."