The True Side of Parity

In last month's Perspective column , Jim DeWees, CP, shared his opinions on the prosthetic parity law in his state of Indiana. While it is unfortunate that Mr. DeWees may have problems with insurance companies, it is not the fault of the parity law. Prosthetic and orthotic parity is the best, though not perfect, solution that we have to help amputees gain fair access to insurance coverage for medically necessary devices. The Amputee Coalition of America (ACA) has worked with state advocates to successfully pass parity bills in 18 states. We salute those who have worked so diligently to get these bills passed. We did not fight for years to change these insurance laws because they were working; we fought to change them because they were unfair and inhospitable to amputees across the nation. Before prosthetic parity laws were passed in these states, insurance companies often capped benefits at $2,500 per year or limited benefits to one limb per lifetime. Some companies even eliminated coverage for artificial limbs completely. These benefit limits were absurd since an adult amputee will need a replacement prosthesis every five years, and growing children will need to replace their prostheses even more frequently. Mr. DeWees said that he was able to get a good policy before the prosthetic parity law. However, the limited benefits in most pre-parity policies certainly would not have constituted "good" coverage for the vast majority of amputees. The fact is that prosthetic parity laws have provided enhanced access to prosthetic care, which has changed the lives of amputees in each of these 18 states. As an amputee and a state advocate who worked to pass parity in my state of Colorado, I can assure you that Mr. DeWees' particular experience is not caused by prosthetic parity legislation. In fact, the problems he describes are caused by insurance policies in general or by an insurance company's failure to comply with Indiana's parity law. Mr. DeWees stated that he had a problem getting a policy that would allow him access to any provider—including those who are not in his insurance company's network. This is common for anyone who has a health plan. Open access to any willing provider is a much larger insurance challenge, one that no one has yet been able to resolve. Parity law is not meant to be a fix for any willing provider; it is meant to ensure that amputees have access to medically necessary prosthetic devices. Mr. DeWees also took issue with insurance companies determining medical necessity. The ACA would also have a problem with such a scenario if it existed. Fortunately, the Coalition's model parity legislation recommends that medical necessity be defined by the treating physician, not the insurance company. Every prosthetic parity law that has been passed requires that physicians determine medical necessity, including Indiana's law (Act. No. 1140). Unfortunately, insurance companies may have to be reminded of this from time to time. After reading Mr. DeWees' statement that insurance companies in Indiana are forcing amputees to sign a "voluntary waiver" of prosthetic benefits due to passage of the prosthetic parity law, we called Anita Strauss, deputy commissioner of health policy with the Indiana Department of Insurance. Ms. Strauss said, "Indiana passed legislation requiring insurers to provide coverage for prosthetic and orthotic devices. This language is 'must provide,' not 'must offer.' It is our understanding that the intent of the legislators was to require coverage for these devices, not to allow insurers to offer waivers to individuals. We would not approve of any waiver for a mandated benefit with this language. If you are aware of individuals receiving an offer to waive coverage from an insurer, please be sure they have that offer in writing and send it to my attention. I most definitely want to know of any insurer in Indiana providing waivers for this mandated benefit." Although Mr. DeWees believes he has been placed in an unfortunate predicament by the prosthetic parity laws, the fact is that these laws give amputees access to affordable prosthetic care. After speaking with the Indiana Department of Insurance, it is clear that they will enforce the law if they are made aware of violations. Our primary reason for responding to Mr. DeWees's Perspective is to reinforce hope for the many amputees across the country who are working on and waiting for prosthetic and orthotic parity in their states and for their health plans. For more information about state parity laws, please visit www.amputee-coalition.org/advocacy/FAQ Jeff Cain, MD, is on the board of directors of the Amputee Coalition of America (ACA). He is also chair of the ACA's Government Relations Committee.

The True Side of Parity

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Pediatric Orthotic & Prosthetic Clinician Department of Orthopaedic Surgery – UCSF

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