Legislative Info
Current Prosthetic Insurance
In the United States
The Problem
An alarming trend in recent years has been the health insurance industry's move to reduce their coverage of prosthetic devices. Many insurers have placed restrictive annual or lifetime caps on prosthetic coverage and some have even eliminated it entirely. Most consumers are totally unaware of this as it is reasonable to assume that any major medical health policy would cover prosthetic care the same as they would cancer, heart attack or any other catastrophic accident or illness.
The Amputee Coalition of America has responded to this threat with the creation of a National Advocacy Department headed by Morgan Sheets, the National Director. Mrs. Sheets has spread awareness of this situation via the ACA's information network and website as well as thousands of hours traveling around the country to assist advocates in starting action groups. Once formed, these advocacy groups have lobbied their state legislatures to enact parity bills aimed at correcting the inequity of these health policies.
As of this writing, 18 states have now passed some form of prosthetic insurance legislation and many more are at some level of consideration. For more information on the ACA's advocacy program, see their website: http://www.amputee-coalition.org or contact Morgan Sheets directly at 202-742-1880.
The Solution
SB1116 – Prosthetic Insurance –The long and winding road to prosthetic parity in Virginia (almost)
In 2006, the Amputee Coalition of America approached Virginia Senator Patricia Ticer and asked that she sponsor a bill that would require health insurance companies doing business in Virginia to provide the same level of coverage for prosthetics as they do for other catastrophic illness or injury. Senator Ticer graciously agreed and at the start of the 2007 Virginia General Assembly Session, she introduced the Bill which started life as SB931.
In the spring of 2007, Senator Ticer and the ACA's National Director of Advocacy, Morgan Sheets, asked Doug Call, President of Virginia Prosthetics to meet and discuss spearheading the campaign for prosthetic insurance parity in Virginia. Call agreed to lead the challenge and appointed his O&P Coordinator, Charlie Coulter, as legislative liaison, and the fight was on.
Coulter spent the rest of the spring and summer learning how the other states with prosthetics bills had managed to get their mandates passed as well as what difficulties he might face in Virginia. It didn't take long to realize that Virginia is definitely an anti-mandate state. During September and October of 2007, Virginia Prosthetics, with the help of a dedicated group of patients and the ACA, were successful in getting the Bill recommended for passage by the Special Advisory Commission on Mandated Health Benefits -- the first step any proposed health insurance mandate must pass in Virginia.
One of the reasons for the Advisory Commission's recommendation was the extremely positive report prepared by the Joint Legislative Audit and Review Commission. The JLARC report cited among other things 1) it was a reasonable presumption that amputees deserved to receive reimbursement from their health insurance for prosthetic care, 2) amputees who received the prosthetic care they needed were likely to return to life as productive members of society which could in turn save the state's social assistance programs, 3) the projected cost for the proposed coverage would be about .24 cents per month.
Early on, Coulter had met with his Roanoke area legislators and everyone with the exception of Senator Ralph Smith agreed that the Bill made perfect sense not only for amputees, but that it would probably save Virginia taxpayers millions of dollars in assistance benefits. Senator John Edwards offered to cosponsor the bill and Delegates Morgan Griffith, William Fralin and Onzlee Ware agreed to offer their bi-partisan support.
When the 2008 General Assembly session began, Coulter moved into a Richmond hotel and began visiting other legislators in an effort to gain their support. Most legislators were extremely hospitable and many agreed that though they would need time to gather their own information and review the Mandated Benefits Commission's recommendation, the bill certainly seem to make sense for all involved. The support of Democrats in both the Senate and the House was almost overwhelming. However the reception from a few select conservative Republicans was not as warm. They expressed a great deal of contempt for mandates in general and claimed that their concern was for business owners, in spite of the fact that their own Legislative Audit Commission's study had stated that the cost would be less than 25 cents per month.
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"It was a very depressing and frustrating experience," said Coulter. "When I arrived in Richmond, armed with the JLARC study and the Special Advisory Commission's recommendation, I figured it would be a done deal. Who could possibly not want to help amputees return to work and regain their lives? But what I hadn't planned on was the fight the insurance lobby was willing to wage against me, and how low they would go to persuade legislators to vote with them. After I started prowling around some of the campaign contribution disclosure sites, such as the Virginia Public Access Project, I began to realize the depth of the insurance industry's powers of persuasion."
After two weeks, Coulter could see that he would need the help of a seasoned lobbyist to successively move the bill forward. He and Call met and interviewed several recommendations before finally hiring Scott Gregory, a seasoned, Richmond-based lobbyist, who in addition to other clients, had represented Trigon Blue Cross/Blue Shield. Coulter thought that the relationship made perfect sense. "Like they say, keep your friends close, and your enemies closer. The best way to anticipate what the insurance lobbyist might do next was to have one working with us and Scott proved to be a great asset."
During the 2008 session the bill was referred to and passed by both the Senate Commerce and Labor and the Senate Finance Committees. After working furiously to swing enough votes in their favor, the bill was essentially stalled on the Senate floor by being referred back to Commerce and Labor for further evaluation. There was not enough time left to get the bill out of committee and back for vote that year.
From March of 2008 until the start of the 2009 General Assembly session, Coulter and Gregory crisscrossed the state meeting with legislators in their local offices. "Scott taught me that the only way to really have a quality meeting with everyone's undivided attention was to meet legislators when they were not in session" said Coulter. "In fairness to them, the General Assembly considers thousands of bills during session and there is no way that they can take the time to really examine a new subject." It was during this time that Delegate R. Lee Ware agreed to sponsor a companion bill in the House so as to speed up the process and increase our chances in the upcoming session. This was a great help as Del. Ware was the chairman of the Special Advisory Commission on Mandated Benefits and is greatly respected by his fellow Republicans who view him as a fair-minded conservative. Delegates Morgan Griffith and Terry Kilgore also agreed to write letters of support to their fellow republicans encouraging them to support the bill.
In preparing for the 2009 legislative campaign, Call and Coulter took a week off to go around Virginia and ask other O&P provider companies to share the cost with Virginia Prosthetics, which until now had been paying the entire cost. Of the more than twenty Virginia O&P provider companies, only five actually stepped to the plate and contributed to the effort in 2009.
By the time the 2009 session convened in January, there wasn't one member of the Virginia General Assembly that hadn't heard of the prosthetics issue. Coulter, Call and Gregory had met with all of the key committee members and just about the entire General Assembly. Those that they had not met with yet had seen amputees wandering throughout the General Assembly building during one of the rallies organized by Virginia Prosthetics and the ACA. Several times during the course of supporting the bill, Virginia Prosthetics had transported amputees to testify before committees and twice had even chartered buses to take as many as 50 patients to Richmond.
2009 seemed to be going a little differently than previous years. Most legislators had now had the time to examine the facts without the distorted views the insurance lobby had painted the previous years. Most were now in agreement that something had to be done to stop the insurance companies from ignoring an amputee's right to proper prosthetic care as part of their rehabilitation. But 2009 also brought several other health insurance topics to the table, chief among these was the issue of coverage for Autism. The cost estimates for this coverage were as much as 100 – 200 times the cost of the prosthetics mandate and there was the growing suspicion that many members of the General Assembly might adopt the avoidance tactic of refusing to pass any mandate in 2009.
The insurance lobby pleaded that if Virginia were to pass all the mandates currently before them it would cause rates to skyrocket. Just days before the deadline for any modification to existing bills, the insurance lobby approached us with a proposition. If we would agree to change the bill from a mandated benefit to a mandated offer, they would reduce their opposition. Though we had succeeded in convincing a large number of legislators to the many benefits of our bill there was still some uncertainty as to how a vote on the floor might play out. There were still a number of legislators who had benefited greatly over the years from generous insurance lobby campaign donations and a few like Senator Ralph Smith who refused to take a position or even talk about it.
In the end, after weighing the options and potential outcomes, it was decided to request that the bill be amended to a mandated offer. This had been done in California and those providers who were contacted in California felt that in seemed to be working there. The modified prosthetic insurance bill, now known as Senate Bill 1116, passed unanimously and was signed into law by Governor Kane in June 2009. The bill will take effect on January 1, 2010 and it will be up to each and every one who supports it to see that it is adhered to by the health insurance companies doing business in Virginia. To see how, just refer to our section; " Monitoring and Enforcement of SB1116"
Everyone involved in the prosthetic parity issue in Virginia learned something, but the most important thing we all learned is that each and every one of us can make a difference. It didn't take thousands of people marching in the streets or millions of dollars of campaign contributions. All it takes is persistence and a legitimate cause. Legislators do listen to their constituents and they realize that for every person who is willing to take the time to visit them or write to them, there are many more who feel the same way and thought they may not make that amount of effort, they will take the effort to remember them on Election Day.
The only local legislator that refused to support the Prosthetics Bill was Senator Ralph Smith. Other than one 10 minute meeting at his Roanoke office where Call and Coulter attempted to explain the bill, Smith refused to ever discuss or give a reason for his refusal to support the bill and on several occasions he actually refused to see Call and Coulter in Richmond after having made appointments to do so. Smith finally voted in favor of the bill on its final passage rather than be the only dissenting vote in the entire Virginia General Assembly. Any Virginia Amputee or Amputee advocate may well want to consider this before ever casting a vote to re-elect Smith.
The following O&P Companies donated to the lobby effort in 2009 and we would like to thank them and ask that if you are a patient of one of these providers, thank them for helping you!
- Albemarle Orthotics & Prosthetics
- Excel Prosthetics & Orthotics
- Hanger Orthopedic
- The Orthotic & Prosthetic Center
- Tidewater Prosthetic Center
- Virginia Prosthetics, Inc.
If your provider is not on the list, ask him why and encourage him to join the newly formed Virginia Orthotic and Prosthetic Association which will be the only unified advocacy voice for Virginia amputees.
What is the difference between a mandated benefit and a mandated offer?
Put simply, in the case of the prosthetic insurance issue;
A mandated benefit would state language similar to "any health insurance company proposing to issue individual or group accident and sickness insurance policies shall provide coverage for the cost of prosthetic devices and components."
A mandated offer however, would state "any health insurance company proposing to issue individual or group accident and sickness insurance policies shall offer and make available coverage for the cost of prosthetic devices and components."
Who will protect my rights as an insurance consumer?
In Virginia, Insurance is regulated by the State Corporation Commission's Bureau of Insurance or BOI. One of their main concerns is consumer awareness and protection. To accomplish the first, consumer awareness, the Bureau makes available a wide range of consumer guides and materials to help you better understand the policy you have purchased or are about to purchase as well as explains about various health insurance coverages. When consumers are unable to reach a satisfactory resolution to a problem after having first tried their insurance agent and or their insurance company, then they can contact the BOI for assistance. The BOI's Consumer Services Section provides free complaint service to all residents of Virginia. To obtain more information go to the BOI website at:
http://www.scc.virginia.gov/division/boi/index.htm
Now that Virginia has passed its first prosthetic parity bill, everyone will be watching to see what happens in January 2010 when the new law goes into effect. During the last part of 2009, insurance companies will be deciding how they will react to this new bill. We have been in contact with the BOI since the bill was passed to find out two important pieces of information. First, how are insurance agents and companies required to disclose this new information to consumers. Secondly, what changes are the various companies making in response to the new law. So far,the BOI has informed us that insurance companies will probably wait until the very last minute to inform the BOI of their intentions. Some companies that already provide adequate prosthetic coverage may not make any changes, some companies that now have caps may simply remove these caps in order to remain competitive in the market. However, some companies which currently have caps may decide to offer a rider at an additional premium. We will try and pass this information along as soon as it becomes available.
