The Affordable Care Act Essential Benefit I Fear Losing as an Amputee


One thing everybody seems to agree on is that the Affordable Care Act, as we know it today, is going to be a thing of the past. The new Congress and President-elect have prioritized repealing the ACA. With the details about any replacement legislation hazy, it is time to rally the limb loss community around an important issue. Since 2010, prosthetic care has been considered an “essential benefit.” Essential benefits are not subject to lifetime limits or payment ceilings. Because of this distinction, insurance companies can no longer subject their limb loss patrons to archaic and debilitating payment caps that were rampant in plans before 2010. Before the Affordable Care Act, $2,500 maximum benefits and $50,000 lifetime benefits were commonplace when prosthetic devices were covered by a plan.

With a repeal of the ACA on the horizon and lacking another concrete plan to take its place, the categorizing of prosthetics as an essential health benefit is in limbo. If prosthetics lose this classification, coverage will likely revert back to the pre-ACA norm. In other words, access to prosthetic devices will be dependent upon the ability for the individual to pay the balance out-of-pocket.

Consider that a $20,000 prosthetic leg, with a $2,500 yearly cap, leaves the payer with a balance of $17,500. With devices breaking down and wearing out, it is conservative to assume that a new one will need to be purchased every five years. All other costs incurred with prosthetic use, including liners and sleeves, will be the sole responsibility of the patient. This financial burden will force many to forgo prosthetic care not because they lack the desire or the ability, but because they cannot afford to walk. Add a lifetime cap of $50,000 into the mix and many experienced amputees will no longer be able to rely upon private payer insurance to help fund their medical devices. Although it is more money up front, research has proven that providing individuals with the prosthetic devices they need actually results in lower insurance costs over time. More information can be found on the Mobility Saves website.

The future of prosthetics as an essential health benefit is in limbo, but there is still time to act. I am encouraging everybody to write to their Senators and Representatives, asking them to keep prosthetic care as an essential health benefit in the plan developed to replace the Affordable Care Act. Congress is taking up this issue this week, and the time to act is now!

I realize that many are uncomfortable writing to their elected officials, but it is paramount that the limb loss community’s voice be heard. A template letter, along with the contact information for elected officials, can be found on www.ampdpod.com.  Because the limb loss community is relatively small, it would be easy for elected officials to overlook our prosthetic needs.

Maintaining the essential health benefit status for prosthetic devices is paramount for access to care and the opportunities and health benefits that come from mobility. Please find a few moments today to send an email expressing your support for maintaining essential benefit status in the replacement legislation. We need to make sure they #DontExcludeAmputees!

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