Re: Prosthetics & Insurance

Re: Prosthetics & Insurance

Tony Barr

Wayne,this info that you forwarded below is concise and accurrate.

Recent HMO trends is why O&P coverage is very limited and becoming none exsistant.

Medicaid O&P coverage,likeTexas are pretty representative of most state medicaid coverage policies eliminating certain age(21-65) groups that most likely to require prosthetic rehabilitation to enter the work force.

Medicare policies require bidding from providers that are not always qualified to deliver quality O&P services.

VA O&P coverages are not consistant in delivering quality care.Reimbursement levels are negotiated.

Vocational Rehab limits ones coverage to their ability to work and that ability is often judgemental (prosthetics provide a means but not always the will!)

Private insurers are pulling back O&P coverages because of projections of more demand of the population(baby -boomers) becoming of age to require O&P services,diabetes and other diseases becoming immune to insulin for prevention of amputation treatment,unreasonable O&P costs,unregulated health care profession,etc.

In a nutshell, if you think you are going to become an amputee and require O&P services,just make sure you are independently wealthy,be sponsored as a O&P manufacturer's rep and able to compete in triathlons, sky dive and mountain climb, be under the age of 21 or over 65, working with workmans comp , a veteran and injured in a war, injured by a well insured driver, or be in a resident in a state that requires that the O&P profession be regulated!!!!! You chances of successfull prosthetic or orthotic rehabilitation is pretty darn good!!

Thanks for the info! Tony

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Sent by a friend. If anyone has corrections or current information,
kindly correct and post:

Wayne Renardson
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There are many forms of healthcare insurance, and not all cover the area
of prosthetics in the same way. Some don't cover it at all. Do you know
what your insurance coverage policy states about prosthetics? SCOPe does
not endorse or prefer one health insurance coverage over another. We
want you to be aware of your coverage and contact your health insurance
provider if you are unaware of the type of coverage you currently have.

Here are some general overviews of common insurance coverages:

Medicare provides fairly comprehensive coverage of prostheses and is
reimbursed through a national fee schedule. Some evidence suggests that
Medicare managed care plans are finding ways to circumvent the full
scope of prosthetic coverage. As Medicare managed care plans shop
between prosthetic providers, quality of care is often sacrificed.

HMOs that are federally qualified are not required to cover prosthetic
services. As more federally qualified HMOs compete for Medicare and
Medicaid beneficiaries, the lack of prosthetic coverage becomes more
problematic.

Medicaid. Prostheses are optional benefits that states may provide under
their Medicaid programs. Although most states provide prosthetic care, a
number of states have arbitrary limitations on coverage, such as
limiting the pool of beneficiaries who may access prosthetic benefits.
For instance, Texas' Medicaid program does not cover prostheses for
persons between the age of 21 and 65. Reimbursements rates have
traditionally been significantly less than private insurance and even
Medicare rates.

Veterans Administration technically provides more comprehensive coverage
than Medicare and until recently used the Medicare fee schedule for
reimbursement. The provision of prostheses to veterans depends on the
local VA prosthetic chief who administers the local program. Prosthetic
coverage, quality of care, and reimbursement waiting times vary as a
result. In the past, the long-standing National Artificial Limb Contract
allowed veterans to choose any private practitioner who signed this
contract to provide their prosthetic care. The new system relies on
regional center, where local VA personnel can designate preferred
providers and negotiate reimbursement levels of the fee schedule.


The Federal Employees Health Benefits Program (FEHBP) provides health
insurance coverage to all federal employees and their families. Under
this program, federal employees have the option to choose from a list of
plans in their area which best fits their needs. FEHBP does not require
minimum coverage of any healthcare benefit; each News Letter (p21 of 21)
plan provides its own separate package of covered benefits and services.
Therefore, coverage of prostheses will vary from plan to plan.

TRICARE, formerly called CHAMPUS is a health care financing program for
the Army, Navy, and Air Force medical facilities. All dependents and
retirees are entitled to Medicare-financed heath care when military
facilities are unavailable. Evidence shows that this program maintains
inconsistent coverage for prostheses and waiting times for provider
reimbursement can be very lengthy.

Workers Compensation has been historically, very generous in their
prosthetic benefits. Any worker who loses a limb is typically covered
under this plan.