By Michelle Andrews, KFF Well being Information
When Michael Adams was researching medical health insurance choices in 2023, he had one very particular requirement: protection for prosthetic limbs.
Adams, 51, misplaced his proper leg to most cancers 40 years in the past, and he has worn out extra legs than he can rely. He picked a gold plan on the Colorado medical health insurance market that lined prosthetics, together with microprocessor-controlled knees just like the one he has used for a few years. That operate provides stability and helps forestall falls.
However when his leg wanted changing final January after about 5 years of on a regular basis use, his new market well being plan wouldn’t authorize it. The roughly $50,000 leg with the electronically managed knee wasn’t medically obligatory, the insurer mentioned, regardless that Colorado regulation leaves that dedication as much as the affected person’s physician, and his has prescribed a model of that leg for a few years, beginning when he had employer-sponsored protection.
“The electronic prosthetic knee is life-changing,” mentioned Adams, who lives in Lafayette, Colorado, together with his spouse and two youngsters. With out it, “it would be like going back to having a wooden leg like I did when I was a kid.” The microprocessor within the knee responds to completely different surfaces and inclines, stiffening up if it detects motion that signifies its consumer is falling.
Individuals who want surgical procedure to exchange a joint sometimes don’t encounter related protection roadblocks. In 2021, 1.5 million knee or hip joint replacements had been carried out in United States hospitals and hospital-owned ambulatory amenities, in accordance with the federal Company for Healthcare Analysis and High quality, or AHRQ. The median value for a complete hip or knee substitute with out issues at high orthopedic hospitals was simply over $68,000 in 2020, in accordance with one evaluation, although well being plans typically negotiate decrease charges.
To individuals within the amputee neighborhood, the protection disparity quantities to discrimination.
“Insurance covers a knee replacement if it’s covered with skin, but if it’s covered with plastic, it’s not going to cover it,” mentioned Jeffrey Cain, a household doctor and former chair of the board of the Amputee Coalition, an advocacy group. Cain wears two prosthetic legs, having misplaced his after an airplane accident practically 30 years in the past.
AHIP, a commerce group for well being plans, mentioned well being plans typically present protection when the prosthetic is set to be medically obligatory, resembling to exchange a physique half or operate for strolling and day-to-day exercise. In apply, although, prosthetic protection by non-public well being plans varies tremendously, mentioned Ashlie White, chief technique and packages officer on the Amputee Coalition. Although protection for primary prostheses could also be included in a plan, “often insurance companies will put caps on the devices and restrictions on the types of devices approved,” White mentioned.
An estimated 2.3 million persons are dwelling with limb loss within the U.S., in accordance with an evaluation by Avalere, a well being care consulting firm. That quantity is anticipated to as a lot as double in coming years as individuals age and a rising quantity lose limbs to diabetes, trauma, and different medical issues.
Fewer than half of individuals with limb loss have been prescribed a prosthesis, in accordance with a report by the AHRQ. Plans might deny protection for prosthetic limbs by claiming they aren’t medically obligatory or are experimental units, regardless that microprocessor-controlled knees like Adams’ have been in use for many years.
Cain was instrumental in getting handed a 2000 Colorado regulation that requires insurers to cowl prosthetic legs and arms at parity with Medicare, which requires protection with a 20% coinsurance cost. Since that measure was enacted, about half of states have handed “insurance fairness” legal guidelines that require prosthetic protection on par with different lined medical providers in a plan or legal guidelines that require protection of prostheses that allow individuals to do sports activities. However these legal guidelines apply solely to plans regulated by the state. Over half of individuals with non-public protection are in plans not ruled by state regulation.
The Medicare program’s 80% protection of prosthetic limbs mirrors its protection for different providers. Nonetheless, an October report by the Authorities Accountability Workplace discovered that solely 30% of beneficiaries who misplaced a limb in 2016 acquired a prosthesis within the following three years.
Price is an element for many individuals.
“No matter your coverage, most people have to pay something on that device,” White mentioned. Consequently, “many people will be on a payment plan for their device,” she mentioned. Some might take out loans.
The federal Client Monetary Safety Bureau has proposed a rule that might prohibit lenders from repossessing medical units resembling wheelchairs and prosthetic limbs if individuals can’t repay their loans.
“It is a replacement limb,” mentioned White, whose group has heard of a number of circumstances during which lenders have repossessed wheelchairs or prostheses. Repossession is “literally a punishment to the individual.”
Adams in the end owed a coinsurance cost of about $4,000 for his new leg, which mirrored his portion of the insurer’s negotiated fee for the knee and foot portion of the leg however didn’t embody the expensive half that matches round his stump, which didn’t want changing. The insurer accredited the prosthetic leg on enchantment, claiming it had made an administrative error, Adams mentioned.
“We’re fortunate that we’re able to afford that 20%,” mentioned Adams, who’s a self-employed management marketing consultant.
Leah Kaplan doesn’t have that monetary flexibility. Born with no left hand, she didn’t have a prosthetic limb till just a few years in the past.
Rising up, “I didn’t want more reasons to be stared at,” mentioned Kaplan, 32, of her determination to not use a prosthesis. A number of years in the past, the biking fanatic acquired a prosthetic hand specifically designed to be used together with her bike. That system was lined beneath the well being plan she has by means of her county authorities job in Spokane, Washington, serving to developmentally disabled individuals transition from faculty to work.
However when she tried to get approval for a prosthetic hand to make use of for on a regular basis actions, her well being plan turned her down. The myoelectric hand she requested would reply to electrical impulses in her arm that might transfer the hand to carry out sure actions. With out insurance coverage protection, the hand would price her simply over $46,000, which she mentioned she will’t afford.
Working together with her physician, she has appealed the choice to her insurer and been denied 3 times. Kaplan mentioned she’s nonetheless unsure precisely what the rationale is, besides that the insurer has questioned the medical necessity of the prosthetic hand. The following step is to file an enchantment with an unbiased evaluate group licensed by the state insurance coverage commissioner’s workplace.
A prosthetic hand is just not a luxurious system, Kaplan mentioned. The prosthetic clinic has ordered the hand and made the custom-made socket that may match across the finish of her arm. However till insurance coverage protection is sorted out, she will’t use it.
At this level she feels defeated. “I’ve been waiting for this for so long,” Kaplan mentioned.
©2025 KFF Well being Information. Distributed by Tribune Content material Company, LLC.
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