Benjamin French was born with his right arm missing below the elbow. In his 12 years, he has been fitted with seven prostheses. His most recent replacement will cost nearly $30,000 and his doctor says he will soon grow out of it.
But, according to his insurance company, the boy is ineligible for further coverage of prosthetic devices because he has already spent his lifetime maximum benefit.
Benjamin's family happens to live in Michigan, one of 33 states where insurance companies are allowed to set annual and lifetime caps on prosthetic coverage. The family's policy with Blue Cross Blue Shield of Michigan covers a maximum of $30,000 per lifetime for prosthetics, plus $1,000 per year for repairs. In states such as Colorado and Maryland, the law says there can be no such cap on prosthetics.
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Within this decade, 17 states have passed laws requiring that insurers pay for prosthetics on par with federal programs such as Medicaid, but in the other 33 states, insurers do not have to offer coverage for prosthetic devices and also can set annual or lifetime caps on coverage. These caps on prosthetics are similar to the caps on mental health coverage that were recently made illegal by a federal mental-health parity law, scheduled to go into effect in January.
"These rules are illogical and arbitrary," said Kimberly Hoyt, a specialist in Denver, Colo., who designs and fits prosthetic limbs. "You have to be an investigative reporter to figure out which states have parity laws and which states don't." Since Colorado became the first state to pass prosthetic parity legislation in 2001, Hoyt said, she has seen fewer denials overall for prosthetic limbs, but gets frustrated when she sees patients, such as college students, who cannot get coverage because they are insured in states with looser rules. ...
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