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Important Information For Virginia Amputees On Prosthetic Insurance Coverage

In 2009 the Virginia General Assembly passed Senate Bill 1116:

Health insurance; mandated offer coverage for prosthetic devices and components.  Requires health insurers, health care subscription plans, and HMOs to offer and make available coverage for the cost of prosthetic devices and components.  This law is effective now and it is up to you and VOPA to make sure insurance companies are complying with the law and that your employer is taking full advantage of it.   The Commonwealth of Virginia does not actively enforce this law.  It is up to us!

What are your rights?  If a Health insurance company’s policy does not cover prosthetics, they must offer it as an addition to your policy if you or your employer accept their terms.  They may charge an extra fee for this coverage.

What is the major difference between “good” and “not so good” insurance coverage?   Coverage of prosthetics varies between insurance companies. Some companies cover prosthetics with no special caps or limits but some companies have very low limits on what they will pay for prosthetics. Be sure to ask exactly what your coverage is and whether there are any caps or limits on your policy. And,:

If your insurance policy treats prosthetic devices as “Durable Medical Equipment” you likely have poor prosthetic coverage.  You may be liable for paying most of the cost for your prosthetic.   For years, insurers have gotten away with lumping what they pay for a prosthetic to the same amounts they pay for a wheel chair. If your policy groups prosthetics under DME, be sure and ask exactly what your prosthetic benefits and limits are.  Before this law passed, an employer or individual buying insurance was often denied the option to have prosthetic insurance coverage beyond “Durable Medical Equipment.”  You now have that right. Take advantage of it!!

Does this law cover group policies?   Yes, but it must be for all employees in that group. Inform your insurance administrator at work and ask if they would request prosthetics coverage. Remember, over 80% of amputations come from diabetes, vascular disease, or cancer. It’s important that everyone realizes their risk.   PLEASE TALK WITH THE HUMAN RESOURCE DIRECTOR OF YOUR EMPLOYER AND MAKE SURE WHAT YOUR CURRENT POLICY COVERS AND MAKE SURE THAT THEY ARE ACCEPTING THE MANDATED OFFER FOR QUALITY PROSTHETIC BENEFITS.

 

Where can I get more information and file formal complaints about prosthetic insurance coverage?  

In addition to the Human Resource Dept. of you employer, please contact us at VOPA and you may also contact the state regulator empowered by the General Assembly to enforce Virginia’s insurance laws.

The Virginia State Corporation Commission’s Bureau of Insurance can provide you with answers to your questions.   They are also required to investigate any complaints associated with compliance of Virginia insurance laws and regulations including the new mandated offer law.  Contact them at:

 

Bureau of Insurance
P.O. Box  1157
Richmond, VA  23218
1-804-371-9691
www.scc.virginia.gov/boi

BureauofInsurance@scc.virginia.gov

Virginia Bureau of Insurance information package containing: Consumer Health Insurance Guide and a Consumer Complaint Guide including a complaint form.

 

Help VOPA HELP YOU:

Below is a list of insurance plans we have identified that have quality prosthetic benefits and those that do not.   If you have a policy not specifically listed below, we are seeking information about your plan and whether or not it belongs on the “Quality Benefits” list or “Inferior Benefits” list.   Please contact us with the name of your insurer and the name of the policy that covers you along the details of your prosthetic coverage and we will add it to our information for other amputees and their employers to review.

Where Can We Go From Here?

The Virginia General Assembly is one of only two state legislatures that have chosen to pass a mandated offer rather than a mandated benefit. Though Congress is considering some form of Federal health care, no one really knows what will be covered, to what extent it will be covered, or when it will be covered.
Working Amputees of Virginia (W.A.V.E.)  
Virginia Capital Building

Virginia Prosthetics patients made many trips to Richmond, to fight for parity.

States That Have Passed Prosthetic Legislation as of July 2010
                       

Mandated Benefit 
Mandated Offer
Arkansas    Colorado  California  Virginia
Utah   New Hampshire    
Oregon   Rhode Island    
Maine  New Jersey    
Vermont Mississippi    
Illinois Massachusetts    
Iowa   Louisiana    
Indiana Maryland    
Texas      

 

The best possible means of ensuring that Virginia amputees receive fair and reasonable treatment from their health insurance companies is to convince Virginia lawmakers that the mandated offer is not enough and that they need to pass a mandated prosthetic insurance benefit.

Review the information contained on the ACA’s advocacy site so that you know the facts.

Contact your state representatives and let them know that this is an important issue. Make them aware of the following:

  • Tell them that Virginia and California are the only two states that passed an offer rather than a benefit. Considering their state’s financial situation, do we really want to emulate California?

 

  • Remind them that our own Mandated Benefits Review Commission reported that this mandated benefit would have minimal impact on small business or individual consumers and that it would probably save the state millions in health, rehab, and social services costs. Because of this, the commission made one of the only favorable recommendations since the commission was formed.
  • Then ask them if they will support a mandated benefit and if not, ask them why?