Good news for those with Lymphedema living in California

Health

Health (Photo credit: 401(K) 2013)

Insurance Coverage of Lymphedema Compression Bandages and Garments Starts Jan 1, 2014 in California.

Robert Weiss, MS
Independent Lymphedema Patient Advocate

The Patient Protection and Affordable Care Act (PPACA) stipulates that all new insurance policies offered in the “Marketplace” effective January 1, 2014 must cover certain “essential benefits” enumerated in the Act. [Ref. Public Law 111-148 Patient Protection and Affordable Care Act §1302(b)(1)(A)-(J)].

The ten covered essential benefit categories are as follows:
• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease management
• Pediatric services, including oral and vision care

The Act, however, does not define what is covered within these categories, and insurance firms can still pick and choose to some degree which specific therapies they’ll cover within some categories of benefit. And the way insurers interpret the rules could turn out to be significant for people with disabilities who need ongoing therapy to improve their day-to-day lives or prevent degradation.

For instance, insurers could choose to cover physical therapy for someone with a broken bone, but not cover long-term support services for chronic conditions, such as lymphedema. The level of benefits insurers have to provide in each category is based on a “model policy” in each state, and some of those model policies are more generous than others.

Also, it is not clear yet how the March 2013 Jimmo VS Sebelius settlement, which eliminates the “improvement standard” in Medicare, will affect the state insurance contracts commencing in 2014.

In anticipation of the need to provide further guidelines to California insurers, the CA Department of Managed Health Care (DMHC) added a new section to Title 28 California Code of Regulations.

Emergency Regulation 2013-4186 added Section 1300.67.005 Essential Health Benefits to Title 28, which became effective on July 5, 2013
[http://www.oal.ca.gov/res/docs/pdf/emergencies/recent%20action,%20moved%20emergencies/2013-0625-02E_App.pdf ]

Included in Section 1300.67.005 Essential Health Benefits (in addition to those services and devices required to be covered under the Knox-Keene Act) was subsection (d)(9)(B)(iii) that included:
“(d) Other health benefits are essential health benefits and are required to be covered as follows:”
“(9) Prosthetic and orthotic services and devices in addition to those services and devices to be covered under the Act.”
“(A) Coverage includes fitting and adjustment of these devices, their repair or replacement (unless due to loss or misuse), and services to determine whether the enrollee needs a prosthetic or orthotic device. …”
“(B) The plan shall cover the prosthetic and orthotic services and devices substantially equal to the following:
“(iii) Compression burn garments and lymphedema wraps and garments, …”

It is extremely gratifying to see how, through a combination of hard work, perseverance and good luck, California lymphedema patients will be covered for their compression bandages, garments and devices 14 years after I initiated action on behalf of my wife Pearl. It is also satisfying to know that these essential items are considered to be “prosthetic device” benefits, a truth I have been unsuccessful in making CMS understand despite confirmatory rulings by dozens of U.S. Administrative Law Judges.

See my LymphActivist’s Site at http://www.LymphActivist.org for details of the events leading to the upcoming coverage of lymphedema compression items.

Thank you Robert Weiss for bringing us this very exciting news and the work you have done towards it… here is a link to the Lymph Activist’s site… http://www.lymphactivist.org/index.php

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