Bill seeks better coverage for artificial limbs
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V.W.H. Campbell Jr., Post-GazetteMorgan Sheets, left, and amputee Kathy Spozio at last week's meeting of the Pennsylvania chapter of the American Academy of Orthotists and Prosthetists at Station Square. Ms. Sheets is the organization's national advocacy director. Ms. Spozio is a member of the Amputee Coalition of America.
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HARRISBURG -- Kathy Spozio lost her leg to cancer 12 years ago. Still, she considers herself lucky.
Ms. Spozio, of Shippenville, Clarion County, has health insurance that paid for the $60,000 prosthetic limb that gave her back her confidence.
It kept her out of a wheelchair, allowed her to be independent and gave her the ability to keep up with her 2- and 3-year-old grandchildren.
Other amputees aren't as lucky.
Some health insurance plans in Pennsylvania evaluate coverage for prosthetics on a case-by-case basis or limit coverage to as low as $1,000 per year and one prosthetic over a lifetime, even for young children who will outgrow the devices, said the Amputee Coalition of America, which is advocating for better coverage.
State Rep. Bernie O'Neill, R-Bucks, wants to change that.
He has introduced legislation that would prohibit insurance companies from instituting lifetime caps on prosthetic devices. The change would set a uniform standard across the state, Mr. O'Neill said at a recent Capitol press conference
Without legislation ensuring coverage, insurers may reduce or eliminate coverage for prosthetics, he said.
People who are born without limbs or lose them to amputation face many obstacles, he said. "Not being able to pay for limb replacement to return to work or lead productive lives shouldn't be among them," he said.
Health insurance companies such as Pittsburgh-based Highmark, Inc., which have a strong Harrisburg lobby, oppose the legislation.
"Benefit mandates negatively impact our customers. They increase the cost of health insurance and they also restrict choice for our customers," said Highmark spokesman Leilyn Perri.
And, he said, Mr. O'Neill's legislation unfairly targets insurance companies because it would not impose similar mandates on businesses that self-insure their employees.
Ms. Spozio, executive board secretary for the Amputee Coalition of America, said her group has studied the cost of coverage for prosthetics in other states, where it has advocated for benefit mandates. In Colorado, the cost would amount to 12 cents per month for each person insured and in California, 16 cents, she said. The group has not studied the cost in Pennsylvania.
Basic prosthetic limbs cost between $4,000 and $10,000, said Frank Erdeljac, of Hanger Prosthetics on the South Side.
"We know of one patient, a pre-teen, with a lifetime cap of $7,000 for prosthetic services," Mr. Erdeljac said. "He's a young person who will continue to grow. He'll certainly outgrow his first prosthesis."
That's why Mr. Erdeljac has joined the amputee coalition's fight for what it calls "prosthetic parity" -- coverage equal to what Medicare provides. Medicare pays at least 80 percent of the cost of prosthetics and allows them to be replaced every five years.
Most people don't realize their policies' limitations on prosthetic devices because no one ever anticipates something catastrophic to happen to them, said Ms. Spozio, who lost her leg in an emergency surgery 12 years ago when a tumor caused a bone to break as she slept.
"It was very hard, at first, to get my mind around all of that. It blows your mind," she said.
Still, she considers herself fortunate; she was able to get a new leg, one with a custom cover and a sophisticated microprocessor that allows her to control the artificial joints using hip muscles.
"If I didn't have insurance [that covered the prosthesis] I couldn't live in the house I live in because it's not wheelchair accessible. My doorways aren't wide enough and I have stairs," Ms. Spozio said. "And I don't think I could do the advocacy work I do. Being able to ambulate and use a prosthetic limb helps me with my self esteem and helped me return to a life that's as normal as it can be.
"Because I'm able to have a prosthetic limb, my life goes on very close to as it did before."
A lot of people she's met through the amputee coalition aren't as lucky.
"These aren't people who don't have insurance. These are people who are paying for insurance policies but don't have [the coverage they need]," she said.
"When something like a diagnosis of cancer drops out of the sky, you can't be worried about who is going to pay for your leg; you have to save your life," she said.
The bill has been referred to the House Insurance Committee. Its chairman, Anthony DeLuca, D-Penn Hills, did not return repeated calls for comment.
Vice Chairman Dan Frankel, D-Squirrel Hill, hasn't yet decided whether to vote for the bill, although he has supported mandates for insurance coverage in the past.
"Mandates aren't always easy because there's always an effect of raising the cost of insurance to people," he said.
Six states have passed similar legislation and at least 20 others are considering it.
The Amputee Coalition of America has launched an advocacy campaign to push for mandatory coverage of prosthetics in all 50 states.
"Our goal is to allow amputees to live their lives to the fullest, whether it is earning a living for themselves and their families or experiencing the everyday joys that are so often taken for granted," said Morgan Sheets, the group's national advocacy director.
First Published May 22, 2007 5:26 pm
