One Limb Per Lifetime restrictions -- do they violate the ACA?

One Limb Per Lifetime restrictions -- do they violate the ACA?

William Lifford

1/20/2015

Hello colleagues,

The past two years, we seem to be running into a significant number of One
Limb Per Lifetime restrictions here in New York (I'll abbreviate it as
OLPL).

As I understand it, the Affordable Care Act prohibits both yearly and
lifetime caps -- such as OLPL -- on Essential Health Benefits (EHBs).
However, prosthetic limbs, which are supposed to be part of the
“rehabilitative devices” EHB, are limited to “one per lifetime” in all the
plans available for sale on the NY State of Health insurance exchange. The
CMS website also has prosthetic limb coverage limited to “one limb per
lifetime” on the NYS Benchmark Plan. How can this be permissible, being
that the ACA is supposed to prohibit such restrictions?



Some states, such as Georgia, do not have such OLPL restrictions. However,
many states, including New York, do.


I know that part of the problem lies in the fact that orthoses and
prostheses were assumed to be part of Rehabilitative and Habilitative
devices and not specifically listed as orthoses and prostheses.


When our amputee patients have problems with OLPL restrictions, being that
this limitation seems to be in direct violation of the ACA’s tenets, how do
you fight this unfair and unlawful restriction? Do we file a complaint
with the NYS Department of Financial Services? Obviously, simply filing an
appeal with the insurance plan is not going to be useful, because their
plan descriptions list the “one limb per lifetime” restriction.


I'd really love to hear your thoughts on this issue and would appreciate
any help you can provide. Of course, I'll post a summary of responses
afterwards for everyone's reference.

Thanks,

Bill Lifford, CP




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William Lifford, CP
Progressive O&P, Inc.
1111 Willis Avenue
Albertson, NY 11784
516-338-8585