Sec. 2. Findings and purpose
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Congress makes the following findings: There are more than 1,700,000 people in the United States living with limb loss, many of whom are appropriate candidates for prosthetic care. A comparable number experience trauma, illness, or disability that results in musculoskeletal or neuromuscular impairment of the limbs, back, and neck requiring the use of orthotic care. Every year, there are more than 130,000 people in the United States who undergo amputation procedures. In addition, United States military personnel serving in Iraq and Afghanistan and around the world have sustained traumatic injuries resulting in amputation and musculoskeletal or neuromuscular injury.
The number of amputations in the United States is projected to increase in the years ahead due to the rising incidence of diabetes and other chronic illness. Those experiencing limb loss and limb dysfunction can and want to regain their lives as productive members of society, and prosthetic and orthotic care often enables amputees and others with orthopedic impairments to continue working and living productive lives. Insurance companies often restrict coverage for prosthetic and orthotic devices and related services over an individual’s lifetime, which shifts costs onto individuals and consequently to the Medicare and Medicaid programs.
Twenty States have addressed this problem and have prosthetic or orthotic parity legislation, which also is being considered actively in other States. The States in which prosthetic or orthotic fairness in coverage laws have been enacted have found there to be minimal or no increases in insurance premiums and have reduced Medicare and Medicaid costs. Coverage of orthotic and prosthetic devices and related services is only appropriate for individuals missing a limb or having an orthopedic condition in need of treatment.
Therefore, a fixed population of individuals are candidates for these devices and related services. Appropriate and timely treatment involving prosthetic and orthotic devices and related services allow people to regain health function, preexisting work, and independent living. Prosthetic and orthotic devices and related services are a distinct and separate benefit from the durable medical equipment benefit, but this distinction often is not recognized as insurers typically combine these benefits under a combined limit.
The Patient Protection and Affordable Care Act ( Public Law 111–148 ) and the Health Care and Education Reconciliation Act ( Public Law 111–152 ), include rehabilitative and habilitative services as an essential health benefit, which legislative history shows is intended to cover prosthetic and orthotic devices and related services. The Institute of Medicine concluded that prosthetic and orthotic devices and related services are covered under a typical employer plan. However, while lifetime and annual dollar limitations on essential health benefits are prohibited under the Patient Protection and Affordable Care Act (Public Law 111–148) and the Health Care and Education Reconciliation Act (Public Law 111–152), other techniques to minimize or eliminate coverage continue to be used across the country and are denying individuals access to medically necessary prosthetic and orthotic devices and related services.
It is the purpose of this Act to require that each group and individual health plan and individual and group health insurance coverage that provides medical and surgical benefits and also provides coverage for prosthetics or custom orthotics (or both), provide such coverage under terms and conditions that are no less favorable than the terms and conditions under which medical and surgical benefits are provided under such plan.
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- Pub. L. 111-148
- Pub. L. 111-152
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Sec. 2
Findings and purpose
Pub. L.Pub. L. 111-148
Pub. L.Pub. L. 111-152
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