Supplemental Coverage for Prosthetic Care

Supplemental Coverage for Prosthetic Care

Michael P Madden

3/13/1998

I have a patient who is in need of prosthetic care. She is presently
working at an entry level pay scale, with an HMO insurance package as
part of her benefits. The HMO has provided some limited coverage for her
prosthesis in the past, but they are not allowing the level of coverage
she needs presently (especially repairs, replacements and maintenance).
She is a functional level K4 patient with functional level K1 coverage.
She is 24, very active, participates in a wide variety of athletic
activities, and I obviously would like to keep her in a system she can
benefit from. Unfortunately the HMO's thinking runs along the line of
prosthetic socks are an unnecessary accessory, not part of basic
prosthetic care. Have you ever discussed Alpha liners and VSP systems
with that logic? She does not want the prosthesis to be her limitation,
and neither do I. She is unable to carry much of a financial burden due
to her income level. She did apply to NYS Medicaid for assistance, but
was informed she makes $100 a month over their income cap for
supplemental coverage.

Does anyone have any information regarding the appeals process or the
likely hood of success with an appeal with NYS Medicaid?

Are there any other agencies and/or programs available for lower income
adults to assist them in paying for prosthetic related care, without
having to surrender their desire to work and get ahead in life?

Any information on similar situations and how those issue's were
addressed (outside of payment schedules) would be greatly appreciated.
I am especially interested in the victories.

Thanks,

Mike Madden BOC(O&P), C.Ped

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