Friday, November 8, 2024

Re: Prosthetics & Insurance

Tony Barr

Wayne,this info that you forwarded below is concise and accurrate.

Recent HMO trends is why O&P coverage is very limited and becoming none exsistant.

Medicaid O&P coverage,likeTexas are pretty representative of most state medicaid coverage policies eliminating certain age(21-65) groups that most likely to require prosthetic rehabilitation to enter the work force.

Medicare policies require bidding from providers that are not always qualified to deliver quality O&P services.

VA O&P coverages are not consistant in delivering quality care.Reimbursement levels are negotiated.

Vocational Rehab limits ones coverage to their ability to work and that ability is often judgemental (prosthetics provide a means but not always the will!)

Private insurers are pulling back O&P coverages because of projections of more demand of the population(baby -boomers) becoming of age to require O&P services,diabetes and other diseases becoming immune to insulin for prevention of amputation treatment,unreasonable O&P costs,unregulated health care profession,etc.

In a nutshell, if you think you are going to become an amputee and require O&P services,just make sure you are independently wealthy,be sponsored as a O&P manufacturer’s rep and able to compete in triathlons, sky dive and mountain climb, be under the age of 21 or over 65, working with workmans comp , a veteran and injured in a war, injured by a well insured driver, or be in a resident in a state that requires that the O&P profession be regulated!!!!! You chances of successfull prosthetic or orthotic rehabilitation is pretty darn good!!

Thanks for the info! Tony

———-

Sent by a friend. If anyone has corrections or current information,

kindly correct and post:

Wayne Renardson

—————-

There are many forms of healthcare insurance, and not all cover the area

of prosthetics in the same way. Some don’t cover it at all. Do you know

what your insurance coverage policy states about prosthetics? SCOPe does

not endorse or prefer one health insurance coverage over another. We

want you to be aware of your coverage and contact your health insurance

provider if you are unaware of the type of coverage you currently have.

Here are some general overviews of common insurance coverages:

Medicare provides fairly comprehensive coverage of prostheses and is

reimbursed through a national fee schedule. Some evidence suggests that

Medicare managed care plans are finding ways to circumvent the full

scope of prosthetic coverage. As Medicare managed care plans shop

between prosthetic providers, quality of care is often sacrificed.

HMOs that are federally qualified are not required to cover prosthetic

services. As more federally qualified HMOs compete for Medicare and

Medicaid beneficiaries, the lack of prosthetic coverage becomes more

problematic.

Medicaid. Prostheses are optional benefits that states may provide under

their Medicaid programs. Although most states provide prosthetic care, a

number of states have arbitrary limitations on coverage, such as

limiting the pool of beneficiaries who may access prosthetic benefits.

For instance, Texas’ Medicaid program does not cover prostheses for

persons between the age of 21 and 65. Reimbursements rates have

traditionally been significantly less than private insurance and even

Medicare rates.

Veterans Administration technically provides more comprehensive coverage

than Medicare and until recently used the Medicare fee schedule for

reimbursement. The provision of prostheses to veterans depends on the

local VA prosthetic chief who administers the local program. Prosthetic

coverage, quality of care, and reimbursement waiting times vary as a

result. In the past, the long-standing National Artificial Limb Contract

allowed veterans to choose any private practitioner who signed this

contract to provide their prosthetic care. The new system relies on

regional center, where local VA personnel can designate preferred

providers and negotiate reimbursement levels of the fee schedule.

The Federal Employees Health Benefits Program (FEHBP) provides health

insurance coverage to all federal employees and their families. Under

this program, federal employees have the option to choose from a list of

plans in their area which best fits their needs. FEHBP does not require

minimum coverage of any healthcare benefit; each News Letter (p21 of 21)

plan provides its own separate package of covered benefits and services.

Therefore, coverage of prostheses will vary from plan to plan.

TRICARE, formerly called CHAMPUS is a health care financing program for

the Army, Navy, and Air Force medical facilities. All dependents and

retirees are entitled to Medicare-financed heath care when military

facilities are unavailable. Evidence shows that this program maintains

inconsistent coverage for prostheses and waiting times for provider

reimbursement can be very lengthy.

Workers Compensation has been historically, very generous in their

prosthetic benefits. Any worker who loses a limb is typically covered

under this plan.

RECENT NEWS

Get unlimited access!

Join EDGE ADVANTAGE and unlock The O&P EDGE's vast library of archived content.

O&P JOBS

The O&P EDGE Magazine
Are you sure want to unlock this post?
Unlock left : 0
Are you sure want to cancel subscription?

Welcome Back!

Login to your account below

Retrieve your password

Please enter your username or email address to reset your password.

The O&P EDGE Magazine
Are you sure want to unlock this post?
Unlock left : 0
Are you sure want to cancel subscription?