Prosthetic Parity: In the Midst of Health Care Reform

With health care reform slowly coming into focus, everyone in the
O&P profession wonders how these new federal laws will affect their
patients and their business. While
parity advocates in some states forge ahead with plans despite
the uncertainty, others have decided to wait out the wave of potential changes
imposed by the federal government.


Since August of last year, both Illinois and Utah pulled off wins for
the cause, signing their parity bills into law. In addition, 17 other states
introduced or reintroduced legislation in 2010, Dan Ignaszewski, government
relations coordinator for the
Amputee Coalition of America (ACA), said.

Still, federal health care reform influenced much of this year’s
legislative session, and caused many states to stall in their parity bill

“A lot of states were hesitant to push through any health care
legislation that would make any kind of mandates or reform at the state level
until they found out what the federal government was going to do,” he
said. “We heard from several federal legislators, saying they were going
to wait … Unfortunately, the parity bills got sidetracked this year.”

By March, when President Barack Obama signed the
Patient Protection and Affordable Care Act, many states were
already in the process of, or close to, wrapping up the session.

Ignaszewski also spoke to O&P Business News about the
progress of individual states in this national effort toward O&P parity.


Tami Stanley, an amputee who was unable to receive a prosthesis due to
one-limb-per-lifetime restrictions, worked against opposition for 4 years to
push the Utah parity bill through the state legislature, making Utah the 19th
state with a parity law.

State Rep. David Litvack, a Democratic sponsor, agreed to draft
legislation and commit to the cause in support of Stanley.

“Here we have a Democratic bill, and we’re in the most
conservative state in the nation asking for a health mandate, and our odds of
this ever passing were like zero,” she said. “I was told that, and
threatened, by the insurance board of Utah.”

But Stanley pressed on, learning the process as she went along.

“Boy, did I learn the process,” she said. “I
single-handedly pushed this issue through and had to do my homework and get
facts and create data. It was an incredible amount of work.”

For the first year, Stanley assembled her information and rallied for
the fight. In the second year, the bill, HB 66, was drafted and made it to the
session and into the business and labor committee — “the toughest
committee in the legislature, purposely, to get rid of it quickly,” she
said — where it was shot down, ending its run for the year. In the
interim, she met with legislators to educate them about the O&P process.

“The third year, [the bill] not only made it out of committee with
flying colors, but it made it to the House floor, and passed, which blew me out
of the water,” she said.

At that point, however, Stanley realized that she only had one week to
recruit a Senate sponsor to carry the bill through the Senate. State Sen. John
Valentine, a Republican, became the bill’s Senate sponsor, but on the last
day of the session, the bill was prevented from being debated on the Senate

This year, legislators, who were more interested in concentrating on
health care reform, threatened to shoot down the issue if Stanley did not curb

“It was a tough year. Opposition was horrible. But in the end, we
were able to get this bill through, and it passed and it was signed by the
governor at the end of March,” she said. “It was nothing short of a

The most important result of the passing of this bill was that it made a
real statement for the issue, Stanley, currently a member of the board of
directors for ACA, said.

Despite her hard work on the cause, Stanley, like many other patients in
the country, does not benefit from the new law because of Employee Retirement
Income Security Act of 1974 (ERISA) regulations — a federal law setting minimum
standards for most private, third-party health care plans. In the meantime, she
is using all that she has learned to help other states through the process.


Although some states initially have worked toward only the prosthetic
end of parity, Illinois was one state to fight for both prosthetics and
orthotics, Jim Kaiser, CP, LP, chief executive officer and clinical and
administrative director of Scheck & Siress O&P and 2010 president of
American Orthotic & Prosthetic Association, said.

“We thought that [insurance coverage for] orthotics was critical,
especially with children — cerebral palsy and spina bifida require some
pretty complex orthotic devices,” he said.

The language of the bill, HB 2652, requires that third party payers
provide no less favorable coverage for custom prosthetics and custom orthotics
than is available under the customary medical benefits of any plan, including
no limits or caps other than those based on regular plan documentation. The
newly passed law pertains only to plans that currently offer prosthetic and
orthotic coverage.

Funded by the Illinois Society of Orthotists and Prosthetists, and
propelled through the lobbying process by a local organization called Families
and Amputees in Motion, the bill was successful, Kaiser said, because of a
critical strategy followed by the groups: setting up a strong local advocacy
group to speak on behalf of patients, and not businesses.

  Dan Ignaszewski
  Dan Ignaszewski

Another factor influencing the bill’s success was testimony from

“We had a young lady with an upper extremity prosthesis, who had
coverage for one prosthesis per lifetime. To exaggerate the situation, we
brought in her original prosthesis from when she was 3 years old,” Kaiser
said. “She’s now 16 years old, and it was obvious that that type of
coverage isn’t adequate.”

Testimony from a child with spina bifida, who relies on extensive
orthotic assistance provided by a reciprocating gait orthosis for her ability
to ambulate, also impacted the legislators, he said.

In total, it cost approximately $20,000 to get this legislation passed,
including a portion of the necessary lobbying fees. Many O&P practices
throughout Illinois, however, were unable or unwilling to financially support
the parity movement.

“Not that they weren’t in favor of it — there was a bit
of an apathetic attitude toward committing resources to be able to get this
project completed,” Kaiser said.

  Tami Stanley
  Tami Stanley

Only a handful of supporters, too, pitched in for the legwork of meeting
with committee chairs in Chicago and with legislators in their local offices.

The new law officially went into effect on June 15, meaning that any
health care plan renewing after that time must include the new language.


In some cases, there is an opportunity to fight for more than what was
written in the initial parity bill. Parity advocates in Maine, who were among
the first in the nation on board with the parity movement, felt that the
original parity bill — HP 15, LD 20 — which became a law in 2004, did
not hold up as acceptable with today’s advancing technology.

“Unfortunately, at that point in time when we passed it, there
weren’t a lot of other states that had participated, and we had to have an
exclusion in there [for] any component that had a microprocessor in it,”
Dave Emery, an amputee and retired mechanical engineer, said. “That was
quite traumatic, because the microprocessor component provides safety, health
and brings people back to work. We were pressured more or less by the insurance

A few years later, after a number of other states passed their own
parity laws, parity supporters in Maine reconvened to press the legislative
body to remove the restriction. They recruited Democratic Rep. Mark E. Bryant
as a sponsor, and the group succeeded; the exclusion will be eliminated as of
January 2011.

The original exclusion also included athletic devices, but the advocates
left that language alone for now, Ignaszewski said.

Integral to the success of this movement in Maine was the Disability
Rights Center in Augusta, Emery said, as well as Kim Moody, the
organization’s director. Through donations from prosthetic providers in
the state, supporters raised about $5,000 and were able to hire a lobbyist for
additional help.

Emery said that Democratic Sen. Peter B. Bowman, the chair of the
insurance and financial services committee, compared prosthetic devices to
other health care devices, like pacemakers, which are necessary and require

“He alluded to his father [who] had a pacemaker years ago and it
wasn’t as functional as the one that he has now,” he said.
“That’s a good comparison of where we’ve been and where
we’re going.”

  Jim Kaiser
  Jim Kaiser

The bill went through a hearing and a financial review, where the
committee found that the change in language would not amount to much of a
change in insurance premiums.

“The increase in cost per premium for an individual in the state of
Maine was pennies. That was good,” he said. “We feel good about


In September 2009, Ignaszewski and the ACA worked with Gloria Price,
founder/executive director of the Amputee Support Group of Delaware, to
introduce prosthetic parity at a Support Group meeting. Democratic state Reps.
Gerald L. Brady and Helene Keeley already had agreed to sponsor and cosponsor
the bill, respectively.

“As the bill moved through the process, other representatives came
on board and we also picked up a sponsor on the Senate side of the aisle,
[Democratic Sen. Harris B. McDowell, III],” Price said.

The bill, HB 343, was assigned to the economic
development/banking/insurance/commerce committee on March 30, and “assures
prosthetic parity for Delaware citizens who have experienced limb loss by
requiring all individual and group health insurance policies provide orthotic
and prosthetic devices at a reimbursement rate equal to the federal
reimbursement rate for the aged and disabled,” she said.

  Dave Emery
  Dave Emery

Despite passing in this committee on April 28, the bill received a
fiscal note once it reached the appropriations committee, saying there would be
a cost to the state for implementation.

Parity advocates met with the committee on May 12 to testify on behalf
of the bill, but it remained in limbo for more than a month.

“We had hoped that after our testimony on May 12, there would be a
vote by the entire House of Representatives and the bill would then advance to
the Senate, assuming it passed,” Price said.

At press time, O&P Business News learned that the bill
did not pass during this session.

Despite having no working knowledge of the legislative process, Price
learned from legal advisers and the ACA while gaining hands-on experience.

“I believe time became our adversary,” she said. “By the
time we had a firm grasp and understanding of the law making process, we ran
out of time.”

Price said she feels confident for the next session, beginning January
2011, and will remain steadfast in the effort until it is passed as law.

She advises other parity advocates to stay strong, and to be prepared to
fight hard and learn the process. She also encouraged taking a nontraditional
approach to outreach.

  After 4 years, Utah became the 19th state to pass a parity law.
  After 4 years, Utah became the
19th state to pass a parity law.
  Image: Tami Stanley

“We had a video made, which was a brief synopsis of prosthetic
parity for all legislators to view,” Price said. “It was a lot easier
than trying to explain the process and was only 7 minutes long. The video was
placed on the website of the Amputee Support Group of Delaware for viewing at
their convenience.”

The video still is available on the group’s website.


Written by Democratic Sen. John Marty and Republican Rep. Maria Ruud,
and introduced by the Minnesota Society of Orthotists, Prosthetists and
Pedorthists (MSOPP) and MNParity, a patient advocacy group, the state’s
O&P parity bill — HF 2379 and SF 2139 — was accepted by both the
House and Senate in May 2009.

Before the groups reintroduced the bill in January 2010, however, they
followed the ACA’s advice and revised it from a prosthetic bill to an
orthotic and prosthetic parity bill.

In its 2010 session, the Senate bill successfully advanced and passed
through all committees, Teri Kuffel, Esq., MSOPP director and vice president of
Arise Orthotics & Prosthetics Inc., said. In the House, the bill passed the
first health committee and was referred to House commerce committee.

Prior to that hearing in March, MSOPP and MNParity granted a request
from Ruud and lobbyist Bill Amberg to table further hearings until the next
legislative session.

  Nick Nelson testified at the 2010 parity hearings in Minnesota.
  Nick Nelson testified at the 2010
parity hearings in Minnesota.
  Image: Greta Nelson

“This decision was prompted by extenuating political factors and
concern that more evidentiary testimony was needed in support of the
bill,” Kuffel told O&P Business News. “All progress
achieved this session through Senate and House will stand firm, and the bill
will ‘pick up where it left off’ during the next legislative session
in January 2011.”

Parity advocates testifying at the 2010 parity hearings included Kuffel;
Rick Miller, CO, president of MSOPP; Jennifer Klein, CPO, MSOPP director; Aaron
Holm, bilateral amputee and founder of nonprofit Wiggle Your Toes; Greta
Nelson, cofounder of patient advocacy group MNParity; and her son, Nick, an
11-year old bilateral amputee and local/national lobbyist.

Holm said he became involved in the cause when it became apparent that
his organization was unable to financially support the needs of the many
individuals requesting assistance with their denied prosthetic claims.

“It was a real eye opener for me,” he said.

The organization then partnered with MSOPP to try to help the limb loss

“Of the 27,000 amputees in the state of Minnesota, there are
approximately 7,500 amputees and countless orthotic patients who would benefit
from the passing of the O&P parity bill,” Kuffel said.

Others who are covered by ERISA-regulated insurance plans would require
help from a federal O&P bill, she said.

Kuffel’s advice to other parity advocates is to be prepared,
organized, tenacious and “be sure to bring amputees who can testify
first-hand to being adversely affected by insurance coverage.”

National effort

Although many people will benefit from these state parity laws, most
O&P patients throughout the United States need something more: federal
parity. For this reason, Ignaszewski and other advocates continue to discuss
with federal legislators the possibility of including at least some form of
parity in the federal health care reform legislation.


Ignaszewski said that they were able to get language in the essential
benefits set that said that insurance plans must cover “rehabilitative and
habilitative services and devices.”

“We have been under the impression … statements have been made
on the floor by a few different legislators and in private by several
legislators … that that language does include prosthetics and customized
orthotics,” he said. “Unfortunately, until we go through the
regulatory process and [receive] confirmation from the Department of Health and
Human Services, we’re going to have some hesitancy to say that it’s
completely accurate.”

Unfortunately, he said, this language does not eliminate the caps and
restrictions, and that is why the state bills remain a necessity. The two need
to work in concert to help the most people.

The federal bill, HR 2575, initially was introduced by U.S. Rep. Rob
Andrews (D-N.J.) in May 2009, and currently has 20 cosponsors. Ignaszewski said
that advocates hope to gain additional sponsors for momentum leading into the
2011 session.

  Teri Kuffel
  Teri Kuffel

Another bill, S 3223, was introduced in the Senate by U.S. Sen. Olympia
J. Snowe (R-Maine) and U.S. Sen. Tom Harkin (D-Iowa) in April 2010.

“What we’re trying to do is to, again, build a relationship
with other senators, to try to increase sponsorship this year to lead into next
year, and see if we can get any movement this year with either the House or the
Senate bill, in terms of a committee meeting,” Ignaszewski said.

In terms of the state numbers, “all but seven states are at some
point along in the process, trying to get initiatives going in their states or
pass legislation,” he said.

ERISA Explained

The Employee Retirement Income Security Act of 1974 (ERISA)
is a federal law that sets minimum standards for most voluntarily established
pension and health plans in private industry to provide protection for
individuals in these plans, according to the U.S. Department of Labor website.

  • requires health plans to provide participants
    with plan information, including plan features and funding;
  • provides fiduciary responsibilities for those
    who manage and control plan assets;
  • requires plans to establish a grievance and
    appeals process for participants to get benefits from their plans; and
  • gives participants the right to sue for benefits
    llowing childbirth — and a 96-hour stay
    in the case of a cesarean section.
  • The Mental Health Parity Act — like the
    federal prosthetic parity law for which O&P advocates are fighting —
    requires group health plans and health insurance issuers to ensure that
    financial requirements and treatment limitations applicable to mental health or
    substance use disorder benefits are no more restrictive than those applied
    medical and surgical benefits.
  • The Women’s Health and Cancer Rights Act,
    which requires group health plans that cover mastectomies to also cover certain
    reconstructive surgery and other post-mastectomy benefits.


According to the U.S. Department of Labor website, ERISA
does not cover group health plans established or maintained by governmental
entities, churches for their employees, or plans that are maintained solely to
comply with applicable workers compensation, unemployment or disability laws.
ERISA also does not cover plans maintained outside the United States primarily
for the benefit of nonresident aliens or unfunded excess benefit plans.

These exemptions are the reason for issues with O&P
parity coverage. Despite the fact that more and more states are passing
individual parity laws, the majority of O&P patients in those states are
excluded from this coverage due to ERISA regulations.

For more information:

Source: U.S. Department of Labor


Questions remain about the future of health care coverage in the United
States, but more and more states are introducing this legislation and working
to pass these O&P parity laws.

“We’ve got states in the Northeast, in the South, on the East
Coast, the West Coast, and all in-between. I think that’s something
that’s really shown that it is a national effort, and it transcends state
lines,” he said. “It’s truly something that is pushing to become
a national movement to make sure that prosthetics and, in many cases,
customized orthotics, are included in people’s insurance plans.”
by Stephanie Z. Pavlou

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