Responses to N.J. Parity post

Responses to N.J. Parity post

They below are the responses to my original post regarding N. J. and O & P
parity. From the reply's I got, it looks like there may still be room for
insurance companies to carve out O & P coverage and set limits. I thought the
idea of Parity was to not allow these activities. I guess we will soon find
out.
David Falk, LPO
 
I am a member of the California Orthotic and Prosthetic Association and
we also have passed a parity bill recently. It sounds like we have
similar language. The issue that we are waiting to see is if insurances
will apply creative language in their benefit offerings to skirt the
ruling. As I recall there was talk that an Insurance Company could carve
out O&P coverage. If they offered the coverage then they would have to
cover the service at the same rate as Medicare. The other issue I
believe was an Insurance Company could create a high enough deductible
that would prevent the ruling to kick in in that colander year because
the deductible was not met.

Don't quote me on this but I believe these were issues.
Parity is a great thing as long as the coverage does not change. Example;
Ins. A now has to cover O and P at medicare allowable. Now, we all know that
insurance companies are the only one's making any money and will do anything to
ensure this remains a fact.
 
Even though it may be mandated that they issue coverage for O and P, they
can certainly put a limit per year or lifetime for this coverage. Patients must
be made aware of this fact and not get hooked on saving money on premiums
without reading the fine print.
An insurance CO. can simply put limits to say, a thousand dollars a year for
prosthetic coverage. They will then pay the thousand dollars at MC
allowable's and leave the rest to the amputee. Their argument will then be Well, we
did not deny treatment, we are just not paying over the max amount. And also
be careful, if you have a contract that states you have to accept what they
pay, you may not have any recourse when trying to bill the patient.
Just food for thought. Pass along if you wish.
 
Dave: I don't' believe the bill has been signed by the governor yet,
and don't forget that as a state initiative it has no impact on all
employer plans where the employer is self-insured. These self-insured
plans are covered by Federal ERISA law and can't be trumped by state
mandates.
Having said that, it is still a nice, positive step in the right
direction. FYI, the Amputee Coalition of American played a very big
role in getting this bill done, and done right. If you have a chance to
send the ACA a thank you note, or if you need help on a parity
initiative in your own state, I would start with them.
 
Does this mean that the current Horizon or Aetna or United contracts at
30-40% below Medicare are going to be paid at Medicare rates?????I agree
with David that it sounds to good to be true.
 
 




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