The latest news from Colorado, Kentucky, Minnesota, New Mexico, and New York
AOPA has received reports from several members indicating significant delays in the prior authorization process for orthotics and prosthetics by Colorado Medicaid. Additionally, reports indicate that Colorado Medicaid is no longer covering
AOPA is planning an outreach effort to Colorado Medicaid on behalf of our members with respect to both of these issues. Please let us know if you have experienced either of these issues in your facility. We would like to have as many AOPA members on the record as possible to assist with this outreach effort.
Kentucky House Bill 224 has passed in the House with a unanimous vote and is pending a hearing before the Senate Health and Welfare Committee. The bill stipulates that the Kentucky Department of Medical Services and Medicaid managed-care organizations (MCOs) shall reimburse prosthetic, orthotic, and durable medical equipment suppliers at no less than 100 percent of what is determined in the state Medicaid durable medical equipment (DME) fee schedule.
Medicaid MCOs are required to cover, at a minimum, the same Health-Care Common Procedure Coding System codes and the same quantities of medical supplies, equipment, or services as are established through the Kentucky Medicaid program’s DME fee schedule.
Additionally, the Department of Medical Services or a Medicaid MCO shall not include a review for medical necessity for equipment that has received a prior authorization, prepayment review, or postpayment review. Once a prior authorization is granted, an MCO or fee-for-services plan is required to continue authorization, at a minimum, for the same amount, duration, and scope until the authorization period ends regarding those equipment, supplies, or services. Medicaid MCOs are required to reimburse suppliers of orthotics, prosthetics, or DME for manually priced items at the manufacturer’s suggested retail price minus 15 percent when there is a suggested retail price. If no suggested retail price is available, the MCO is required to pay at the invoice price plus 20 percent. The Department of Medical Services must require the allowable timeframe for claim submissions to be equal to the timeframe for any discrepancy during the Medicaid MCO’s audit or recoupment period.
An appropriations bill to fund an advanced digital technology center for orthotics and prosthetics has been introduced in Minnesota. H.F. 537 would appropriate $15 million from the general fund to the commissioner of employment and economic development for a grant to Century College for development of an advanced digital technology center for orthotics and prosthetics to provide workforce training and education on high-end digital technologies, with a focus on innovation and industry collaboration. This is a one-time appropriation and is available until expended.
New Mexico House Bill 70, Insurance Fairness for Amputees, passed through the House chamber and is now on its way to the Senate for consideration. The Amputee Coalition is encouraging O&P stakeholders living in New Mexico to take a moment and contact their New Mexico state senator to ask for support. The organization has set up a letter-writing campaign that can be accessed at www.amputee-coalition.org.
Two bills pertaining to prosthetic coverage have been introduced in the state of New York.
New York Assembly Bill 5328 has been introduced, which requires individual, group, or corporate policy to include coverage for the purchase of prosthetic devices to compensate for the loss of a limb and is prescribed by the treating physician or other licensed health-care provider. The coverage is subject to annual deductibles and coinsurance but consistent with other benefits in the policy. It does have language that states, “Such coverage may be limited to one prosthesis for the life of the policy.”
New York Assembly Bill 4812 also has been introduced. The legislation requires health insurance companies to provide coverage for the replacement of a prosthetic device in the event it is lost or stolen. It also requires replacement of a prosthetic limb for a child until the age of 19 as often as required or prescribed by the child’s physician.