A Multi-State Analysis of the Fiscal and Social Impact of Commercial Insurance Coverage for Recreational Prostheses in the United States

Main Article Content

Shaneis Kehoe, CO, MS Jeffrey Cain, MD Angela Montgomery, CPO Lindi Mitsou, CPO,MSPO

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

How to Cite
KEHOE, Shaneis et al. A Multi-State Analysis of the Fiscal and Social Impact of Commercial Insurance Coverage for Recreational Prostheses in the United States. Medical Research Archives, [S.l.], v. 11, n. 5, may 2023. ISSN 2375-1924. Available at: <https://esmed.org/MRA/mra/article/view/3809>. Date accessed: 21 july 2024. doi: https://doi.org/10.18103/mra.v11i5.3809.
Section
Research Articles

References

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