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Rule change means state health insurers must provide replacement prosthetics

Dan Bastian, vice president and co-founder of Progressive

Dan Bastian, vice president and co-founder of Progressive O&P, seen on April 16, 2013, lost much of his right leg to a rare cancer about 35 years ago. He now operates a prosthetic business helping rebuild legs and limbs for others. Photo Credit: Newsday / Alejandra Villa

Health insurers beginning next year will be required to cover replacements and repairs for prosthetics, reversing the "one prosthesis per limb per lifetime" restriction that insurance plans on the exchange had adopted.

The state Department of Health said it was changing the policy for 2016 based on clarification from the federal government.

Under the Affordable Care Act, states had to provide "benchmark" plans that determined the specifics of essential 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 did so, making New York's coverage among the most restrictive in the country.

After objections raised by amputees, Sen. Kemp Hannon (R-Garden City), chairman of the Senate Health Committee, and other legislators sent a letter April 28 to Donna Frescatore, executive director of NY State of Health, urging her to "eliminate this unjustified provision."

In a response dated May 13, Frescatore said the federal Department of Health and Human Services had clarified "that the federal statute requires coverage of devices for both rehabilitative and habilitative services." As a result, she said, "New York's benchmark plan will be modified starting on January 1, 2016 to include coverage for the cost of repair and replacements of external prosthetics."

Hannon applauded the change, saying "I'm actually delighted. It's common sense and a significant improvement for those who need a change in their prosthetics."

Daniel Bastian, 49, of Massapequa, agreed. An amputee and co-founder of Progressive Orthotics and Prosthetics in Albertson, he started an online petition that garnered more than 15,500 signatures and met with about 50 legislators to change the benchmark coverage.

"I'm happy it's fixed -- and in a relatively short period of time," said Bastian, who started the petition on March 4.

But he said he would continue to push for passage of a bill in both the state Senate and Assembly to ensure that prosthetics were covered and that a physician -- not an insurance company -- determined the medical necessity of the device.

"This way it's a permanent fix," he said.

David McGill, president of the National Association for the Advancement of Orthotics and Prosthetics, said Frescatore's determination "sets a really important precedent for amputees in other states."

Utah, Alaska and Puerto Rico offer no coverage at all, according to the Amputee Coalition in Manassas, Virginia. Nevada places a limit of $10,000 per lifetime per person.

Prosthetics generally last three to five years and can cost from $5,000 to $80,000, Bastian said.

Only two plans on New York's exchange now offer more than the minimum, according to the state health department: BlueShield of Northeastern New York, offered in the Albany area, and BlueCross BlueShield of Western New York, offered in the Buffalo area.


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