The National Association for the Advancement of Orthotics and Prosthetics (NAAOP) released a new webcast about the advocacy efforts the organization is leading regarding the Affordable Care Act (ACA), particularly coverage of orthotics and prosthetics as essential health benefits (EHB) under ACA plans. NAAOP General Counsel Peter Thomas, JD, said there has been a flurry of recent activity on this front with some modest victories and some new challenges, as follows.
Centers for Medicare & Medicaid Services (CMS) Issues Final Regulation on EHBs: On February 20, CMS issued a final regulation that interpreted EHBs for plan years 2016 and 2017. CMS further regulated the definition of “habilitative services” in this final rule, thereby creating a federal floor for coverage of these services. This benefit is part of the ACA statute that mandates coverage of ten categories of benefits including rehabilitative and habilitative services and devices. However, neither CMS in its prior regulations nor the National Association of Insurance Commissions (NAIC) explicitly recognized coverage of “devices” until now.
The new regulation explicitly says that habilitation services include devices and that the term “rehabilitation services” should be treated the same way. It also says that that if insurance plans impose limits on these benefits, they must be imposed equally on rehabilitation and habilitation. Finally, in 2017, ACA health plans will have to apply separate benefit limits on both rehabilitation and habilitation services and devices. The regulation did not specifically list orthotics and prosthetics as mandated benefits, but the new language cited above provides additional arguments for O&P advocates to use at the state level to clarify coverage of O&P care.
O&P Coverage Challenges in New York and California: NAAOP is working diligently with advocates at the state and federal levels to challenge O&P coverage limits in New York and California. In New York, the EHB benchmark plan limits coverage to one prosthesis, per limb, per lifetime; and in California, there is serious confusion as to whether the state’s benchmark plan covers prosthetic limbs at all. NAAOP is helping to coordinate and orchestrate strategies in each state to oppose these limitations with the goal of having them removed from states’ EHBs.
Federal Challenge to ACA (King v. Burwell): NAAOP is closely monitoring the Supreme Court of the United States as it prepares to hear oral arguments challenging federal subsidies in the 34 states that use the federally facilitated exchange to provide ACA health insurance to their residents. The decision in the case will not come until June, but the outcome may have a profound impact on the future of the ACA. It is estimated that more than seven million Americans will lose their health insurance if the plaintiffs challenging the law win their case. It would then fall to Congress and the Obama administration to try to implement stop-gap reforms to limit the fallout from the decision.
At issue in the case is whether a five-word passage in the massive bill, which refers to subsidies flowing through “state” exchanges, means that such subsidies cannot flow through the federal exchange. Without these subsidies, millions of Americans would not be able to afford health insurance coverage under the law. It is a classic legal challenge pitting those who strictly interpret statutes against those who believe Congress’ laws must be read in context, said Thomas.
The webcast is posted on the NAAOP website and on oandp.com, shared with members via e-mail, and made available through the NAAOP page on Facebook.