A Multi-State Analysis of the Fiscal and Social Impact of Commercial Insurance Coverage for Recreational Prostheses in the United States
Main Article Content
Abstract
Despite overwhelming evidence that physical activity is critical for health [1][2], prosthetic devices designed for recreational activities such as running, biking, and swimming are excluded from the vast majority of insurance coverage plans in the United States. Unlike devices designed for walking, recreational prosthetic devices are specifically designed for recreational activities. Using walking-specific devices for recreation has been shown to fail under excessive strain and cause long-term physical and behavioral negative side effects [3][4].
Exceptions in coverage for these devices currently exist in the United States’ Veteran healthcare system, or are undergoing revision through various state legislative initiatives. Maine and New Mexico recently passed bills into law, while Colorado (CO), Connecticut (CT), and Illinois (IL) have bills in process applicable to commercial insurance plans [5]. The objective of this policy review is to analyze current applicable policies, available actuarial data and 2022 US Census population data to determine the fiscal and social impact of bills under consideration during the 2023 Legislative Session [6][7]. As a result, the increased per month per member (PMPM) to cover these devices was calculated to estimate the relevant state’s fiscal impact:
- CO: House Bill (HB) 23-1136 is conservatively calculated at $0.01- $0.08
- CT: planned fall 2023 proposed bill is conservatively calculated at $0.01- $0.11
- IL: Illinois Senate Bill (SB) 2195 is conservatively calculated at $0.01 - $0.37
These estimated costs are less than 0.04% of the annual average amount spent on healthcare (per capita) in the United States ($10,000) [8]. Despite spending the highest amount per capita among first-world countries, the United States has the lowest life expectancy. This disparity highlights the need to reconsider preventative health services not currently covered, likely attributing to the high cost per capita in the US. Based on these findings, expanding insurance coverage to recreational prosthetic devices in Colorado, Connecticut, and Illinois would result in potential short and long term physical and behavioral health benefits as relevant social impacts. Consequently, the current definition of "medical necessity" should be expanded by the commercial insurance industry based on recent research [9].
Article Details
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
2. Title 24-A, §4315: Coverage of Prosthetic Devices, https://legislature.maine.gov/statutes/24-A/title24- Asec4315.html.
3. American College of Sports Medicine, Why We Must Prioritize Equitable Access to Physical Activity for Children with Disabilities: https://www.acsm.org/blog-detail/acsm-blog/2021/03/22/prioritize-equitable-access-to-physical-activity-for-children-with-disabilities
4. Outcomes for Persons with Limb Loss: and Stauffer, LC. “Department of Health and Human Services - Maine.gov.” MaineCare Comprehensive Rate System Evaluation Interim Report, 20 Jan. 2021, https://www.maine.gov/dhhs/sites/maine.gov.dhhs/files/inline-files/MaineCare-Comprehensive-Rate-System-Evaluation-Interim-Report-2021.01.20.pdf
5. Federal Register. (n.d.). The Federal Register. Federal Register :: Request Access. Retrieved April 14, 2023, from https://www.federalregister.gov/documents/2020/12/28/2020-27014/prosthetic-and-rehabilitative-items-and-services
6. Maine Bureau of Insurance, Review and Evaluation of LD 1003 An Act to Improve Outcomes for Persons with Limb Loss:
https:/www.maine.gov/pfr/sites/maine.gov.pfr files/inline-files/LD1003-Maine-Mandated-Benefit-Athletic-Prosthetic-Report.pdf
7. U.S. Census Bureau QuickFacts: Maine; Colorado. (n.d.). Census Bureau QuickFacts. https://www.census.gov/quickfacts/fact/table/ME,CO/AGE295221
8. Our World In Data (n.d.). Life Expectancy vs. Health Expenditure Per Capita, 2019. https://ourworldindata.org/grapher/life-expectancy-vs-health-expenditure-per-capita
9. 40 Amputee Coalition, Help Us Introduce the Insurance Fairness for Amputees Act: https://www.amputee-coalition.org/wpContent/uploads/2018/04/insurance-fairness amputees-act.pdf
10. Senate Bill 22-040 by senator(s) Smallwood and winter ... - colorado. leg.co.gov. (2022, June 8). Retrieved April 14, 2023, from https://leg.colorado.gov/sites/default/files/2022a_040_signed.pdf
11. Who we are. CIVHC.org. (2022, September 12). Retrieved April 14, 2023, from https://civhc.org/about-civhc/who-we-are/
12. Orthotic and Prosthetic Care In Co. Hanger Clinic. (n.d.). Retrieved April 14, 2023, from https://hangerclinic.com/clinics/CO/
13. Executive Director of the Department of Health Care Policy and Financing. (n.d.). HCPF. Retrieved April 14, 2023, from https://hcpf.colorado.gov/
14. 41 KAISER FAMILY FOUNDATION. (2023). Health Insurance Coverage of Children 0-18. kff.org. Retrieved February 20, 2023, from https://www.kff.org/other/state-indicator/children-0-18/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
15. Legislative Council staff nonpartisan services for Colorado’s ... (n.d.). Retrieved April 14, 2023, from: https://leg.colorado.gov/sites/default/files/r20-238_health_insurance_mandates_0.pdf
16. Public act no. 18-168 - connecticut general assembly. (n.d.). Retrieved April 14, 2023, from https://www.cga.ct.gov/2018/ACT/pa/pdf/2018PA-00168-R00HB-05163-PA.pdf
17. Illinois General Assembly . (n.d.). 215 ILCS 5/356z.18. Retrieved April 14, 2023, from https://www.ilga.gov/legislation/ilcs/documents/021500050K356z.18.htm
18. FAQs - aopanet.org. (n.d.). Retrieved April 19, 2023, from https://www.aopanet.org/wp-content/uploads/2022/09/SKCM-FAQs-FINAL.pdf