Update: The National Battle for Prosthetic Parity

After several years of spreading knowledge, awareness and prosthetic coverage to people across the United States, Morgan Sheets, national advocacy director for the Action Plan for People with Limb Loss (APPLL), says the movement for prosthetic parity truly is, at this point, a national trend. Since the opening of the 2007 legislative session, the efforts toward coverage have been in full swing across the United States with 26 states currently involved in some part of the push for parity and several more considering joining the fight.

This is inspiring information coming off the heels of a recent survey conducted by Hanger Orthopedic Group in conjunction with the Amputee Coalition of America (ACA) compiling prosthetic coverage restrictions.

According to Sheets, surveys were sent last fall to facilities in 10 states (Texas, Pa., N.Y., N.J., Fla., Conn., Iowa, Wash., Va. and Tenn.). Surveys were collected and compiled for six states (Texas, Pa., N.Y., N.J., Fla., and Conn.). There were 123 respondents. The findings were not necessarily surprising but only because it was expected that the restrictions would be steep. That does not make them any less alarming.

“We are seeing that at each of the state levels where we often do these surveys, they just don’t make sense,” John Rush, MD, chief medical officer for Hanger Orthopedic Group, said. “Prosthetics are restorative and every one of these bills saves money for the state and will do so for the country on a national level.”

Financial restrictions spanned from $1,000 per year to a $65,000 lifetime cap and interjected exclusions, including limitations on myoelectric above elbow prostheses and refusal to cover battery replacements. One policy actually refused to cover prostheses at all defining them as cosmetic. These findings gathered information concluding that at least 38 different companies are imposing restrictions on prosthetic coverage.

This information released in February shows why it is more important than ever to launch a new or support an existing prosthetic parity campaign before coverage is further restricted. O&P Business News presents an update on a state-by-state basis on where the states closest to passing bills stand.

There are plans for additional outreach to the executive office in Iowa in an effort to develop more support at that level and educate the legislators that have been recognized as most likely to back the effort.

The Iowa bill has gained momentum but unfortunately stalled as the House Majority Leader would not bring the bill up for debate on the floor. Senate file 508 passed the Senate 37-11 and was eligible for a floor vote when session adjourned in April.

“Next year, when they reconvene in January, [the bill] will be alive again and essentially in the same place it is now,” Justin Hupfer, lobbyist working for the Iowa Prosthetic, Orthotic and Pedorthics Association said. “The good news is a lot of progress was made. We made it through the Senate and through the commerce committee in the House but then we ran out of time and it stalled.”

Making this a particular struggle this past session was issue awareness. In the House, holding twice as many members as the Senate, it is hoped that once outreach efforts and education increase, so will the support behind the bill. The Senate was also already familiar with the topic as it had been introduced two previous years in that chamber, Hupfer explained.

“There were a lot more initial contacts to make in the House and a large number of [people to] educate about the bill,” Hupfer said. “I think next year we’ll try to have one larger rally sometime in late January to get a larger number of patients to come up to the capitol on one certain day. We know which members in the House we need to target.”

Sheets also added that there are plans for additional outreach to the executive office in Iowa in an effort to develop more support at that level and educate the legislators that have been recognized as most likely to back the effort. Also, a meeting was held recently with Sen. Tom Harkin, a member of the Iowa Congressional delegation. He indicated that he is willing to help push this legislation through in his home state.

While it should have been a passage this year, Sheets is confident that with these added efforts, Iowa will be a success story next year.

The bill is now being reviewed by the Senate Budget and Appropriations Committee, and may pass in the second half of the legislative session of 2007.

The New Jersey bill has significant support increasing the likelihood that it may pass in the second legislative session of 2007.

The Senate bill, S502, passed out of committee in mid-May. At that time, they also began to consider the addition of an amendment which would extend mandatory coverage to all New Jersey government employees under the New Jersey State Health Benefits program, explained Dennis O’Donnell, a representative from Amps in Action in Marlton, N.J.

The bill is now being reviewed by the Senate Budget and Appropriations Committee. The ACA is working with the lobbyist through this process to ensure that it makes it to the floor for a vote.

Assembly bill, A1011, is already eligible for a floor vote. If the amendment to the Senate bill is accepted, that could delay advancement of the House vote until the amendment is replicated in the House bill.

“The assembly bill is actually sponsored by the chair of the insurance committee so that is a really strong advocate to have as we move to the floor vote,” Sheets said.

The bills have been at a standstill since their introduction for reasons outside the control of activists and well-organized leadership.

The New York bills (S01672 and A01274), while there is tremendous support behind them, have been at a standstill since their introduction for reasons outside the control of activists and well-organized leadership. The bill remains stagnant in the House because there has not yet been an appointment of a new chairperson of the Assembly Insurance Committee since the former was appointed to a new position.

“This has resulted in little activity since the chair typically takes the lead in responding to requests for hearings on the bill,” Peter Purdy, a volunteer working for the cause said.

Purdy is confident that once a new chair is appointed, hopefully early next session, momentum will resume and some changes will start to come together.

On the Senate side, the bill is essentially being held up due to adversity from the current chairperson, Sen. Jim Seward. Additionally, a proposed bill to amend current mandate considerations is adding to the delay.

“There is a bill pending that would require all bills related to mandated care to go through a special review commission, a similar process to some other states, and Seward has refused to let this bill move forward because he wants it to be considered by this commission first,” Sheets said. “This is disappointing since we have the data and research to demonstrate the basic cost and impact data associated with this bill.”

Hundreds of calls have been made and informational materials have been dropped off at the necessary offices. Additional outreach with the help of House sponsor, Assemblywoman Aileen Gunther, has been arranged to try and gain the support of the lieutenant governor, who in the past has been supportive of disability rights issues and causes.

The support of his office might be just what is necessary to push this bill forward, Sheets explained.

Enlisting the help of organizations and individuals outside the O&P industry who held similar goals and obtaining strong professional help were two of the key factors that led to the final passage of the bill.

Oregon’s bill (HB2517) was passed into law after only 10 months of organized planning, giving added hope to states that are thinking of mobilizing for action, Sheets explained, making this the seventh parity law passed.

“The Oregon Orthotic and Prosthetic Association (OOPA) is having a great year. We have managed to pass a parity bill that has real teeth and will help many people,” Forest Sexton, CPO, president of OOPA and owner of Spectrum Orthotics & Prosthetics Inc. said. “I believe that this has been a unique success story.”

The organization’s success lies in several aspects of the planning process. Enlisting the help of organizations and individuals outside of the O&P industry who held similar goals and obtaining strong professional help were two of the key factors that led to the final passage of the bill. The ACA worked with OOPA each step of the way. The bill was passed in May. It will become official in July.

Participation in organized rallies, lobby meetings and press conferences is paying off and increasing interest and drive. The bill is on target to be through the House by summer recess and enter the Senate by the fall.

The Pennsylvania bill was reintroduced during the first half of the legislative session and is moving along well and gaining momentum. Currently in the House Insurance Committee, activists are putting pressure on the insurance committee chair to push for a hearing, Sheets said. The ACA has been given the commitment that the committee vote would be complete in June so that the bill could then go to the floor and hopefully be through the House by the summer recess allowing it to enter the Senate in the fall.

“Representatives from the ACA, Pennsylvania Orthotics and Prosthetic Society and the Pennsylvania chapter of the American Academy of Orthotists and Prosthetists recently came together at the state meeting to educate their members and strategize for future efforts,” Kathy Spozio, ACA board member said. “The cooperation of these professional organizations has meant a lot to the continuing movement of House Bill 317. The power of statewide activism has been key.”

Sheets added that participation in organized rallies, lobby meetings and press conferences is paying off to help increase interest and drive.

The lobbyist for the Tennessee Orthotics Prosthetics Facilities Inc. currently is quantifying and pinpointing the specific types of policies in Tennessee. This summer will likely consist of compiling and presenting the lobbyist’s findings to decision makers in the legislature to raise awareness.

Tennessee was scheduled to hold hearings regarding bills (HB2145 and SB2147) in both the Senate and House Commerce Committees in early May. Unfortunately, the bills have not been given official consideration in either committee at this time, Sheets said.

Michael Adler, lobbyist for the Tennessee Orthotics Prosthetics Facilities Inc., commented on the resistance that the bills are currently facing from the insurance industry.

“The vast majority of the health care plans offered in Tennessee by the major carriers are inclusive of these procedures and we are making the point that while that is true for those carriers, it is certainly not all,” he said. “We are in the process of quantifying that and pinpointing the specific types of policies that are in Tennessee.”

This summer will likely consist of compiling and presenting their findings to the decision makers in the legislature to raise awareness, he explained. The bill uses “any willing provider” language, which is only adding to the struggle, but Adler is confident that the groups will be able to come to terms on the arrangement. Another language problem Tennessee faces is being sure not to affect the Medicaid benefits through the wording of parity legislation.

In Tennessee, private carriers participate in a managed care program which has been scaled back during the past few years. There is a fiscal note on the Tennessee bill which Adler describes as egregious providing the example that the Tennessee bill “sets the minimum benefit at the CMS Medicare/Medicaid rate and [these institutions] claim that they historically pay 30% below that level,” Adler said. “So we have to come up with some language that accommodates that.”

Despite these obstacles, it is not completely unlikely that Tennessee could pass before the end of the second 2007 legislative session. They did an incredible job of advancing their licensure bill in a short period of time and have a precedent of getting policy [passed] pretty quickly, Sheets said.

Colorado: Seven Years Later   Jeffrey J. Cain As the first state to pass parity legislation in 2000 and implement it in 2001, Colorado has come a long way in implementing their law and educating insurance companies about how they are required to provide appropriate prosthetics to their insured patients. Now in full swing, amputees in Colorado are living fuller and less stressful lives because they can now afford the prosthetic technology their lives demand. O&P Business News checked in with Jeffrey J. Cain, MD, chief of family medicine at The Children’s Hospital in Denver to uncover how the climate of the industry has changed since implementing the law. As the founder of the Colorado Coalition for Working Amputees, the group that passed their state mandate, Cain has been at the forefront of this movement since its inception. The process Starting a group to change insurance law in Colorado required thorough planning, but they unexpectedly found the talents necessary to mobilize were already present within the amputee support group community. Cain explained they just needed direction coming together and working through the legislative process together as a team. At the end of the day, they had some fun, too. That is not to say that there was not a lot of hard work involved in the process, Cain amplifies, adding that even though the movement took awhile, it was an exciting time. “One of the lessons that we got out of Colorado is that both citizens and legislators see this as an issue of justice and fairness…everyone assumes that if they were hurt that adequate prosthetic coverage already exists inside their insurance policies, and everyone was appalled to find that it was not,” he said. Legislators from both sides of the aisle supported their successful drive to pass a law mandating coverage to the same extent as Medicare. Also, it is important to keep in mind that once legislation is passed, there is still work to be done. “There is still a time when you have to educate the insurance industry about the changes to ensure that their policies complied with the law,” Cain said. “Also, it takes an active consumer to be able to understand the law and make certain that the law is interpreted appropriately when they request prosthetic services.” The group was also successful in defending their law in later years when legislators in Colorado succeeded in eliminating many other insurance mandates, but not prosthetics, in an attempt to decrease insurance costs. The payoff Six years ago, people were slowly losing the little prosthetic coverage they had and worrying about how they would afford prosthetic coverage. Today the same coverage that was threatened is assumed and expected. “Insured patients are now able to get the kinds of prosthetic devices that they need on a medical basis and not worry about whether the insurance company is going to cover them,” he said. “They are able to access the kinds of devices that are medically appropriate, whether it is a computerized knee or an athletic foot – if it is medically appropriate and prescribed by their treating physician, they know their insurance company is ultimately going to have to cover it.” Additionally, the end result of the hard work helped not only the amputee community, but the population of Colorado as a whole. “We ended up making a difference not just in our own lives but for the lives of everyone in Colorado that potentially faces amputation,” Cain said. “Passing the law was an immensely satisfying experience for our group.” — Jennifer Hoydicz, staff writer

At the session’s close, the final version of the bill did not include the prosthetic parity amendment. Activists cite a lack of support from the governor’s office as one of the possible causes.

The Texas bill had a successful run this past legislative session and was expected to pass just before the session closed for recess; however the session adjourned without passing the bill.

After being assigned to the state consent calendar which essentially signals tremendous support for passage, the bill was added as an amendment to a preexisting bill (SB23) sponsored by Sen. Jane Nelson.

“It is not uncommon that if you want to move your bill and it is not moving as a stand alone… to introduce it as an amendment to another bill,” Sheets said.

Unfortunately, at session’s close on May 29, the final version of the SB23 did not include the prosthetic parity amendment. Activists working on the bill in Texas cite a lack of support from the governor’s office as one of the possible causes for the amendment being removed, Sheets said. The ACA intends to work with the local committee to educate and persuade the governor and his staff on the merits of the policy.

Virginia Prosthetics Inc. is working hard to make all O&P providers and patients aware of the issue at hand and get them heavily involved in its resolution.

The Virginia Senate bill 931 entered the multi-step process to passage when it was introduced in January.

But, before the bill can move forward, it is under the scrutiny of two different review commissions: the Special Commission on Health Insurance Mandates and the Joint Legislative Audit Review Commission.

“They are charged with advising the governor and the general assembly on the social and financial impact of current and proposed mandated benefits and providers,” Jeremiah Perez, national advocacy specialist for the ACA, said. “This will delay the bill from even reaching a committee until 2008, after both commissions review the merits and propose an executive summary.”

J. Douglas Call, CP, president of Virginia Prosthetics Inc. also weighed in on the progress of the bill so far.

“[The commissions’] decision is the great unknown at this point,” Call said. “I am doing everything I can as an O&P provider to inform and educate the commission members about the issue and why parity legislation is so important to patient care and quality of life. To date, I have been disappointed at the lack of action other O&P providers in Virginia have displayed toward supporting this issue. I encourage them to get on board now and support this legislation for their own benefit as well as their patients.”

With the help of the ACA, Virginia Prosthetics Inc. is working hard to make all O&P providers and patients aware of the issue at hand and get them heavily involved in its resolution.

“[The groups] distributed a letter to every O&P provider in the state encouraging them to get on board by having their patients sign a petition of support and by making their voices heard,” Call said.

The Special Commission has scheduled a hearing for the bill on Sept. 20.

APPLL Helps Lead Coalition to Launch Federal Bill With individual state legislation underway or passed in half of the country, the Action Plan for People with Limb Loss (APPLL), spearheaded by Morgan Sheets, the national advocacy director for APPLL, is beginning to compile information to set a federal bill in motion. Gaining support In the beginning stages right now, they are starting to investigate the process and speak to some of the key players in Congress. “What we are really working to do over the next year is start to lay the groundwork to try to introduce a congressional bill and start to try to do some outreach to the members of the key committees,” she said. By gaining a large level of support, it is more likely that the proposed bill will be streamlined through the necessary committees for review and stay in motion rather than running through the mill, so to speak. Launch is expected to be this summer in those states that have not yet begun their own parity legislation. “We want to start some initial outreach and education into the states that have members on key committees who we haven’t been working with a lot on the parity issue to start to build that capacity and that level of awareness,” Sheets said. “That way, when it gets to the point where we’re introducing a bill, we will have a strong base of knowledge and a strong base of activists.” Why a federal bill? “The reason why we want to endeavor to pass a federal bill is of course because that then becomes the law of the land and we don’t have to go state by state,” Sheets said. “It also means that plans that are regulated by federal law would be impacted whereas they would not be impacted by state bill.” For example, there are extenuating circumstances that could prevent someone from getting the correct care, including coverage regulated at the federal level or if a patient lives in a state with parity legislation but receives care out of state. “A federal bill then becomes all encompassing for any private insurance plans regardless of where or how they are administered and so that is important,” Sheets said. There are some states that will be exceptionally difficult to pass health care legislation within where it could take years to move a bill. Federal legislation would encompass those more cumbersome states as well. With that being said, Sheets assures that efforts toward state-by-state parity are not being sidelined, but instead being one part of a comprehensive effort. “It is smart for us, as an advocacy organization, to continue a multi-pronged effort,” Sheets told O&P Business News. “We want to reach as many people as we possibly can and eventually reach the goal of passing the federal bill.” By using both the state and federal avenues to gain parity legislation, more people will get involved. Those who are not necessarily involved in state politics have the opportunity to participate in the federal arena and vice versa. Either way, those participants will be working towards the same end – access to prosthetic care. This also will help to jump start additional interest. “I think the efforts on Capitol Hill will only strengthen the efforts underway in each of the states,” Rush said. “When I testify in the states, no state wants to be alone and be the only one passing something…so they see that there are other states passing this legislation and that there’s a national bill underway, it really helps in that state-by-state effort.” – Jennifer Hoydicz, staff writer

Next states in line

Maryland, Michigan, Ohio and Illinois are the next in line to introduce their cause to state leaders. Maryland’s plan of approach is a little different due to preexisting selective regulations already in place.

“Maryland has a couple of administrative regulations that require prosthetic and orthotic coverage for certain areas of health care,” Sheets said. “The ACA is looking to introduce additional legislation that seeks to close the gap to include all insured residents.”

She added that Maryland looked like a positive state to pass said legislation because of that precedence.

Identify allies, build support, reach out to new partners

Michigan, Ohio and Illinois have a more traditional parity struggle in their cases. These states intend to use the second half of the legislative session to spread awareness.

“It is likely that those will wind up being bills that will use that time in the fall session to educate, identify who our allies are and start to build support so we can truly move it in the 2008 session,” Sheets said. “It is difficult to pass a bill in the second session that has not moved at all in the first half so generally the goal of that is to get some momentum behind the bill for the following session.”

“We will use this summer to build and enhance our current states and really reach out to new partners. We are also looking to start the roll out of the federal bill through a set of education and outreach initiatives,” Sheets concluded.

For more information:

• www.amputee-coalition.org/advocacy/index.html. Accessed on May 30, 2007.

Jennifer Hoydicz is a staff writer for O&P Business News.