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Defining Orthotics and Prosthetics in a Reformed System and Ensuring Funding
for O&P

Definition of Orthotics and Prosthetics

Now that the health care reform bill, the Patient Protection and Affordable
Care Act, has been enacted, the extensive work of implementing the bill has
begun. As part of that process, the Department of Health and Human Services
(HHS), in conjunction with the National Association of Insurance
Commissioners (NAIC), will be developing regulations and standards by which
insurance plans must comply in order to operate within state Health
Insurance Exchanges, set to take effect in 2014.

The NAIC held a series of interim meetings on health care reform
implementation in July. At that meeting, the Commissioners presented draft
definitions of "rehabilitation" services and "durable medical equipment"
(DME), two terms that must be defined so that consumers can easily compare
coverage across private health plans. NAAOP, along with its Alliance
partners, attended these meetings and were ready with recommendations to
ensure that O&P is not defined as durable medical equipment. Instead, we are
advocating that the NAIC separately define "orthotics and prosthetics."
Toward that end, we suggested a definition for NAIC to adopt: "Prosthetics"
include artificial legs, arms, and eyes and "orthotics" include leg, arm,
back and neck braces that are ordered by a health care provider, including
replacements due to wear, damage, or a change in the person's medical
condition." These definitions are intentionally simplistic and are designed
to be understood by a wide range of health care consumers who may know very
little about health care terminology.

In connection with this advocacy, we also pointed out to the NAIC that
Congressional intent lays the foundation for the NAIC to use its discretion
to include a separate definition in the list of medical terms for
"Prosthetics and Orthotics." House Education and Labor Chairman George
Miller (D-CA) explicitly stated in his floor statement during House passage
of the bill that Congress intended to include prosthetics and orthotics in
the essential benefits package under the term "rehabilitation and
habilitation services and devices." Congress also intended to define
prosthetics and orthotics separately from "durable medical equipment" in the
definitions section of the Affordable Care Act. NAAOP was a leader in
ensuring this floor statement was submitted for the written record by
Chairman Miller.

Vital Medicaid Funding Proposal Passes the Senate

The Senate voted 61-39 on Thursday, August 5th, to finally send to the House
of Representatives a $26 billion state aid package that would provide $16.1
billion to extend enhanced Medicaid funding for states. The Federal Medical
Assistance Percentage (FMAP) funding proposal had been attached to several
legislative vehicles over the past months, but each time it was stripped or
the vehicle failed to pass in the Senate. The funding is enough of a
priority for Democrats that Speaker Nancy Pelosi (D-CA) has called back the
full House of Representatives from recess next week to vote on the bill.
Speaker Pelosi's decision on Wednesday afternoon came hours after the Senate
achieved cloture on the legislation due to the support from Maine
Republicans Susan Collins and Olympia Snowe.

The package extends by six months enhanced federal Medicaid payments, so
that states will have enhanced funding until the end of FY 2011. The
recovery bill (also known as the "Stimulus Package" enacted last year
included the initial increase of funds for Medicaid but these increases are
scheduled to expire by December 31, 2010, halfway through most states'
fiscal year. The Senate bill stops short of extending the funding until June
at its current amount. Instead the bill phases-down the funding until it
runs out in June 2011. This Medicaid funding increase, along with
approximately $10 billion in increased education funding to prevent teacher
lay-offs is fully "offset" by other spending reductions, namely, changes in
the tax code and rescissions of other funding, including money meant to
extend the food stamp program.

The National Conference of State Legislatures reports that most states have
budgeted for the upcoming fiscal year on the assumption that Congress will
approve a six-month extension to the enhanced FMAP. Without the extension,
state governments have warned of drastic cuts to Medicaid benefits and
reimbursement rates.

Even with the enhanced funding contained in this new bill, most states are
under serious pressure to reduce expenditures, and Medicaid is always a
likely target. In this respect, the O&P community must remain vigilant to
oppose any cuts in Medicaid coverage throughout the states. Just recently,
the O&P community has seen the threat of reduced O&P coverage become
reality, as Arizona decided to eliminate orthotic coverage for adults over
21 years of age and California contemplated significant cuts in O&P
coverage, only to restore them after public opposition to these proposals.


Please visit our website at: www.naaop.org

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www.naaop.org