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Prosthetic Benefit Caps: A Bad Option for Everyone 

Jennifer Latham Robinson


Healthcare for the uninsured is a hot topic these days. Newscasters are talking about it, politicians are talking about it, your Aunt Edna is talking about it… but little attention is paid to the quality of benefits for those of us with existing group coverage. As a working amputee with premiums paid up to date, it’s easy to assume that the group health plan would include adequate coverage for a prosthetic limb. There would inevitably be a financial portion due from the patient, like a deductible or co-insurance. But overall, many presume the insurance company would at least cover a substantial portion of prosthetic costs.
In recent years a disturbing and contagious trend has emerged in the coverage guidelines for many group health insurance plans. These plans have isolated prosthetic benefits and decided that this coverage is unnecessary. By which process was the necessity of these prosthetic limbs determined? The limitations and exclusions vary from plan to plan. Dollar amount capitations for benefits, as low as $1,000.00 per year in many cases, are common. There are also limitations on the frequency of replacement, such as one prosthetic replacement every three years or even one prosthetic replacement per lifetime. Benefits can also include limitations on the circumstances surrounding a prosthetic replacement; for example, covering replacement only when due to childhood growth.        
Who are the insurance executives creating these coverage limitations? We do not know their names. Deborah Bradnick, Adcock Financial Group Vice President and specialist in employee benefit issues, agrees that the process by which these specific benefit limitations and exclusions are determined can be mysterious. However, the motives are more obvious. Amputees are a smaller population of the employee group and the challenge for most employers is to keep premiums down for the majority of employees. In her experience, “some employers believe that most employees won’t be affected by a certain plan limitation, so the limitation is justified to them”. According to Ms. Bradnick, “most employers do not realize that there may be a severe limitation or exclusion for prosthetic and/or orthotic devices when they buy into a plan”. Insurance agents typically supply prospective employers with a general breakdown of benefits and costs, which may or may not include all limitations and exclusions. In her dealings with employers, Ms. Bradnick likes to supplement this general plan breakdown with a manual spreadsheet that includes additional limitations or exclusions that could affect the employee population. However, Ms. Bradnick stresses that insurance agents are not required to provide this detailed information to employers.  Companies that deal in the medical field, specifically prosthetics, “could be more aware of these issues and would know to specifically check for good prosthetic benefits”. 
Self funded insurance plans allow employers to more directly participate in the design of employee benefits. Ms. Bradnick points out that “larger companies may opt for a self insured plan, where they have more control”. A self funded insurance plan is not purchased directly from an insurance company. Instead, the employer is directly responsible for payment of claims.   This eliminates accounting for the profit that insurance companies usually receive from employers, a profit that is built into the premiums. However, if claims exceed the expected amount, the employer could be at financial risk. An amputee covered under a self funded plan may be able to approach the employer, who designed the benefits, and request for a revision or exception to be made. Self funded plans, which are not regulated by State law, are still the rarity.  Most employees living with limb loss still struggle with nameless insurance executives who seem ill-informed about their prosthetic needs.

What employers don’t realize is that including adequate prosthetic coverage in a standard insurance plan would only cost a few cents a month in insurance premiums. This extremely low cost for the masses is a striking contrast when considering how devastating these benefit cuts are for the amputee. Employee productivity aside, a lack of necessary prosthetic care can reduce an individual’s overall activity level and decrease functional independence. With a decrease in activity level and increase in stress, the long term health cost could swell beyond expectation.         
To the insurance company, though, the amputee is typically just an identification number. Insurance companies are rarely provided with a window into a plan participant’s life, where benefit limitations and exclusions have life altering consequences.
Randy is 41 years old. He has been married for twelve years. His wife’s name is Tina and they have two young daughters. He has worked for a major supermarket chain for twenty years in the meat department. Currently, he works from the corporate office in the meat training department and is responsible for forty stores. Randy underwent a knee disarticulation (through the knee) amputation in May of 2002, after a boating accident. Usually a joker, Randy smiles more seriously when he thinks about life without a prosthetic leg. “There is no way I would be able to work without it”. 
Randy and his wife believe people are generally ill-informed about their group health plan coverage. His group insurance paid practically 100% of the care for his emergency services. However, shortly after the accident Randy and Tina received troublesome news in the mail. There was a new limitation on coverage, coincidentally, for prosthetic care. His plan would now only cover approximately a third of the cost for a typical above the knee prosthesis. “No one explained our coverage to us”, Tina says. Randy adds, “My wife has addressed it with the group benefits department and they say they can’t do anything. She explains to them how much a prosthesis costs and how much we have to pay out of pocket. They don’t care. They’re probably thinking they’re glad it’s me and not them”. 
For someone like Randy, there is little choice in the matter. His employer, like many, does not offer a variety of insurance plans to workers and the plan was in effect before his amputation, when prosthetic coverage was not a concern. When asked how this makes him feel, Randy reflects, “It makes me feel like they don’t care about their employees. That maybe an amputee should quit their job and loose everything in the hopes that Medicaid or Medicare will give that person a leg. It makes me feel like the general public thinks amputees aren’t important”.      
Randy lives life optimistically and continues to work, on his feet every day. Years ago, Vocational Rehabilitation, a Division of Florida’s Department of Education, supplemented the payment by Randy’s insurance company and provided funding for the majority of his prosthetic care. Since then, however, Florida’s Vocational Rehabilitation has instituted a process called ‘order of selection’, which places applicants for funding on a waiting list. The applicants are placed on the waiting list based on the severity of their disability. Since Randy does not live with a cognitive or communication disability, he would be placed at the bottom of the list. In addition to ‘order of selection’, his assets and income would now be a consideration in his eligibility for funding assistance. 
Quitting work is not an option for Randy. His wife thinks anxiously ahead, to the next time Randy needs a major prosthetic component replacement. “Well, I try not to think about it,” Tina admits. “I do know it’s going to come soon because Randy is very active and never takes his leg off. It is not an option for us. He has to have it. We have already taken the girls out of private school to be able to cover expenses”. But Randy isn’t stopping there. He has written a heart-felt letter to Senator Bill Nelson (D-FL) and watches hopefully as state and federal legislation develops toward ensuring Prosthetic Parity. This would require group health insurance companies to reimburse for prosthetic devices on par with federal programs like Medicare, where coverage is based on medical necessity are there are no dollar amount capitations for prosthetic benefits. “Hopefully,” Randy adds, “I hold out until then”.


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