New York State's benchmark insurance policy under the Affordable Care Act originally had an odd clause in its coverage for artificial limbs, allowing for only "one external prosthesis per limb per lifetime."
Because most health plans in New York's exchange marketplace follow the state's benchmark, thousands of adult amputees faced a ridiculous situation where their insurance plans wouldn't cover replacement prosthetics, which can cost up to $80,000 and might last just a few years.
Thanks to advocacy from amputees and elected officials including State Sen. Kemp Hannon (R-Garden City), the state Department of Health now says its benchmark plan, Oxford EPO, will include coverage of the repair and replacement of prosthetics beginning next January.
The ability to replace prosthetics is not only important because they wear and age, or because patient needs shift, but also because amputees should benefit from continued improvements in technology.
The state Department of Health says the change will cover the cost of repair and replacement due to "normal wear and tear" or if a device is outgrown. Hannon said he hopes to clarify details including, for instance, whether a woman will be covered if she needs multiple prosthetics as her body changes during a pregnancy. We'd like to see a benchmark plan that sets a uniform standard with broad coverage based on what physicians, not insurers, think is medically necessary.
Because insurance coverage changes year to year, state lawmakers should make prosthetic coverage based on a doctor's determination permanent.