The National Association for the Advancement of Orthotics and Prosthetics (NAAOP), through its membership in three coalitions, including the O&P Alliance, responded to the interim final regulations on patient protections. These regulations include rules forbidding the future use by insurance companies and health plans of pre-existing conditions exclusions in the group and individual insurance markets, as well as restrictions on the use of lifetime and annual caps on insurance coverage. All of these patient protections accrue to the benefit of people in need of O&P care and the providers who serve them, according to an NAAOP press release.
The Patient Protection and Affordable Care Act (PPACA) prohibits insurance companies from imposing pre-existing condition exclusions on children younger than 21 years of age in all group and individual plans beginning Sept. 26. Adults are covered within this policy in 2014.
The new law also prohibits plans from setting lifetime limits on coverage of essential health benefits and from setting unreasonable annual limits prior to 2014, with all annual limits phasing out once new health insurance exchanges are established and operational in that year.
Since these new restrictions only apply to the provision of essential health benefits, the definition of this term is critical to the O&P field. The PPACA mandates that insurance plans sold through exchanges include coverage of “rehabilitative and habilitative services and devices” as an essential health benefit. While there is good legislative history that this category of benefits includes coverage of O&P care, the statute does not further define the scope of all categories mandated as essential by PPACA. HHS may not publish the proposed regulation on the essential benefits package until 2011 or beyond and, therefore, continued advocacy is critically important to ensure that O&P services and devices are considered essential benefits, the press release reads.
When fully operational in 2014, these protections will significantly assist consumers of O&P care to access appropriate treatment, but in the meantime, unintended consequences may occur. For instance, incentives exist for insurance health plans to shrink their core benefit plans so as to broaden the kinds of services they place caps on in the short term. These kinds of incentives are not only a threat to patients trying to access coverage prior to 2014, but may set up a poor precedent for the regulatory battle that will define the basic benefit package for decades.
To counteract these threats to coverage of O&P and other services, NAAOP, along with over 40 other national rehabilitation and disability organizations, argued forcefully in written public comments that HHS should:
- Impose a regulatory moratorium on all new annual caps on essential benefits imposed by health plans that did not impose annual limits prior to the bill’s enactment; and
- Use its authority to prohibit all coverage changes that would subvert the intent of the PPACA’s prohibitions on lifetime and unreasonable annual caps as well as the prohibitions on pre-existing condition exclusions (i.e. intentionally shrinking benefit coverage to avoid the new restrictions, with the effect of limiting medically necessary services).