An Arm or a Leg is Not a Luxury!

Missouri Coalition for People with Limb Loss

(MCPLL)Established in 2007

What is the MCPLL?

• The MCPLL consists of:– Amputees

– Prosthetists– Business owners

Mission Statement

• The Missouri Coalition for People with Limb Loss (MCPLL) works towards the access of resources for Missourians experiencing limb loss and encourages parity through advocacy, networking, and education.

The Leaders of MCPLL

– Jeff Damerall, Chair; – Jean Freeman, Vice-Chair, Secretary– Jim Weber, Treasurer– Debbie Wilson, Hospitality Chair– Bill McLellan, Fundraising Chair

About MCPLL• Established in 2007 to address the

disparity in insurance coverage for prosthetic devices.

• Currently working for passage of prosthetic parity legislation in Missouri in 2009.

Everyone is a potential amputee

Potential causes of amputation:• Diabetes• Peripheral Vascular Disease• Motorcycle and auto accidents• Farm and industrial accidents• Home accidents • Violence

Amputation is an unexpected, traumatic event that may create

extensive medical, emotional, and rehabilitative needs.

Prosthetic Coverage: Saving Money and Saving Lives

• Nearly 2 million people in the United States currently live with limb loss, about 29 thousand in MO. – Prosthetic devices can allow amputees to live as

productive members of society. – Prosthetic devices cannot provide the same function

as an arm or a leg.

The Need for Prosthetic Parity

• United Health Care: $2500 per year cap, once-in-a-lifetime clause

• Mercy Health Plans: $5000 per year cap

• Anthem BCBS: $4000 per year cap

• Average cost of BK prosthesis: $8-10,000

• Average cost of AK prosthesis: $12-20,000

• Average time a prosthesis can be worn comfortably: 3-5 years

The Cost of Prosthetic Provision

The average cost of providing prosthetic coverage is less than $2 per year — pennies per month.

– The Colorado Department of Health Policy and Financing found that the cost of providing prosthetic coverage would be 12 cents per member per month.

– The California Health Benefits Review Program estimated the cost to be about 16 cents per member per month.

A Policy That Saves Dollars and Makes Sense

• Providing prosthetic devices costs very little to the general insured population and saves money in the long run.

• Without prosthetic care, many individuals will lead a more sedentary lifestyle.

• Secondary complications and even death can result from sedentary lifestyles.

Savings to the State

• Private insurance coverage prevents shifting costs to the public sector.

• Amputees using prosthetic devices can continue to be contributing members of society.

Savings to the State

• If amputees are prevented from accessing prosthetic care, this increases state Medicaid costs.

• Conditions that can increase state costs include: – Flexion contractures– Skin breakdown– Osteoporosis– Muscle loss– Depression

Organizations in Support of Prosthetic Coverage Legislation:

• Abilities Fund• American Academy of Family Physicians (AAFP)• American Academy of Orthotists and Prosthetists (AAOP) • American Board for Certification in Orthotics, Prosthetics and

Pedorthics (ABC)• American Congress of Community Support & Employment Services• American Congress of Rehabilitation Medicine• American Medical Rehabilitation Providers Association • American Orthotic and Prosthetic Association (AOPA) • Disability Service Providers of America• Johns Hopkins Bloomberg School of Public Health, Injury Research

& Policy • National Association of State Head Injury Administrators• One Percent Coalition• The Orthotic and Prosthetic Alliance

SECOND REGULAR SESSIONHOUSE BILL NO. 210094TH GENERAL ASSEMBLY  INTRODUCED BY REPRESENTATIVES COOPER (155) (Sponsor) AND AVERY (Co-sponsor).                  Read 1st time February 12, 2008 and copies ordered printed.D. ADAM CRUMBLISS, Chief Clerk4999L.01I AN ACTTo amend chapter 376, RSMo, by adding thereto one new section relating to health insurance coverage for prosthetic devices.

Be it enacted by the General Assembly of the state of Missouri, as follows:

            Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be known as section 376.1223, to read as follows:            376.1223. 1. Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery,

continued, or renewed in this state on or after January 1, 2009, shall provide coverage for prosthetic devices that, at a minimum, equals the coverage provided under the federal Medicare program under 42 U.S.C. Sections 1395k, 1395l, and 1395m and 42 CFR 414.100, 414.202, 414.210, and 414.228. The coverage required under this section shall include all services and supplies medically necessary for the effective use of a prosthetic device, including formulating its design, fabrication, material and component selection, measurements, fittings, static and dynamic alignments, and instructing the patient in the use of the device.

            2. For the purposes of this section, the following terms shall mean:            (1) "Health benefit plan", the same meaning as such term is defined in section 376.1350;            (2) "Health carrier", the same meaning as such term is defined in section 376.1350;            (3) "Prosthetic device", an artificial limb, device, or appliance designed to replace in whole or in part arms, legs, or eyes as set forth in 42

U.S.C. Section 1395x(s)(9).            3. A health carrier may require prior authorization for prosthetic devices in the same manner that prior authorization is required for any

other covered benefit.            4. A health benefit plan may be subject to coinsurance or co-payments on prosthetic devices in an amount not to exceed the coinsurance or

co-payment amounts imposed under Part B of the Medicare fee-for-service program. A health benefit plan shall reimburse for such prosthetic devices at no less than the fee schedule amount for such prosthetic devices under the federal Medicare reimbursement schedule.

            5. Covered benefits under this section shall be limited to the most appropriate model that adequately meets the medical needs of the insured to perform activities of daily living and essential job-related activities, as determined by the insured's treating physician.

            6. The coverage required under this section shall include any repair or replacement of a prosthetic device that is determined medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities.

            7. The health benefit plan shall not impose any annual or lifetime dollar limits on coverage for prosthetic devices other than an annual or lifetime dollar limit that applies in the aggregate to all terms and conditions covered under the plan.

            8. The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months' or less duration, or any other supplemental policy as determined by the director of the department of insurance.

What’s Next for the MCPLL• Raise $70,000 from prosthetic facilities

and individuals before the start of the 2009 Legislative Session.

• Reintroduce Prosthetic Parity bills in the Missouri House and Senate.

• Be willing to compromise on a mandated offer but not on individual policies.

• Build a grass roots organization throughout the state.

• Recruit volunteers and new members

Questions?

For Further InformationJeff Damerall, Coalition ChairMissouri Coalition for People with Limb Loss (MCPLL)12801 Flushing Meadow DriveSt. Louis, MO 63131314-853-1910http://molimbloss.blogspot.com