LymphActivist's Site
Dedicated to Lymphedema Patients and the Therapists Who Treat Them
LymphActivist's Site
Dedicated to Lymphedema Patients and the Therapists Who Treat Them
LymphActivist's Site
Dedicated to Lymphedema Patients and the Therapists Who Treat Them
Insurance Coverage of Lymphedema Compression Bandages and Garments Starts Jan 1, 2014 in California.
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 essential benefit categories are: a) Ambulatory patient services; b) Emergency services; c) Hospitalization; d) Maternity and newborn care; e) Mental health and substance use disorder services, including behavioral health treatment; f) Prescription drugs; g) Rehabilitative and habilitative services and devices; h) Laboratory services; i) Preventive and wellness services and chronic disease management; and, j) 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.
see Habilitative Services
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
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.
Events Leading to California Coverage of Lymphedema Compression Items
It is informative to review the events that led to the inclusion of the requirement to cover lymphedema compression bandages and garments in California from the point of view of a lymphedema patient activist in California.
1998: California Assembly Bill AB 7 (Brown), enacted in1998, requires "Every health care service plan contract that is issued, amended, renewed, or delivered on or after January 1, 1999, that provides coverage for surgical procedures known as mastectomies and lymph node dissections, shall … cover all complications from a mastectomy, including lymphedema". This same year Congress passed the Women's Health and Cancer Rights Act of 1998 (WHCRA).
The Women's Health and Cancer Rights Act of 1998 (WHCRA) is a federal law that provides protections to patients who choose to have breast reconstruction in connection with a mastectomy, including coverage of any physical complications at all stages of mastectomy, including lymphedema. This law applies to three different types of coverage:
1999: Since January 1, 1999 treatment of lymphedema resulting from mastectomies and reconstructive breast surgeries has been covered under some insurance plans, but not Medicare. Lymphedema from other sources, as well as primary lymphedema, were not explicitly covered by law. Moreover, the definition of what constituted covered lymphedema services was not defined by law, and was left to the interpretation of providers and insurers.
2000: My wife Pearl and I were covered at that time by a Kaiser Permanente Medicare Advantage plan under a retiree group policy. Our bandages and compression garments were not being covered as we felt they should be, since the treatment of sequela of mastectomies are covered by law and that treatment includes the constant use of compression. My series of claims and appeals to Kaiser and subsequent complaint to the California Department of Labor and the successor Department of Managed Health Care (California State agencies having oversight for health management organizations) resulted in an affirmative determination and Kaiser agreed to provide compression bandage systems and compression garments to Pearl starting July 1st, 2000.
2001: Although Kaiser Permanente basic prosthetic and orthotic device coverage has included compression bandages and garments since July 1, 2000, patients were not informed until 2001, and the changes were said to be effective January 1, 2002. In its Individual Plan Summary of Changes for 2002, Kaiser Permanente informed its California subscribers that they were covered for lymphedema compression wraps and garments, exactly three years after enactment of the federal Women's Health and Cancer Rights Act of 1998 (1999 Omnibus Consolidated and Emergency Supplemental Appropriations Act (HR 4328: P.L. 105-277)) and the California Breast Cancer Patients Protection Act (AB-7 Brown).
Kaiser covers "compression burn garments and lymphedema wraps and garments" as part of their basic Prosthetic and Orthotic Devices coverage, "including fitting and adjustment of these devices, their repair or replacement (unless due to misuse) and services to determine whether you need a prosthetic or orthotic device." "Non-rigid supplies not covered by Medicare, such as elastic stockings and wigs" are excluded. There is no co-pay for the provided prosthetic and orthotic devices.
2005: My California bill AB 213 Liu in 2005-6 Health Care Coverage for Lymphedema attempted to define and cover lymphedema treatment according to the complete decongestive therapy protocols, including the coverage of compression items, was withdrawn when an oncologist's group objected to being told how to practice medicine and gutted the bill after it had passed the Assembly Committee on Health.
2010: The Patient Protection and Affordable Care Act (ACA) (Public Law 111-148), as amended by the Health Care Education and Reconciliation Act of 2010 (Public Law 111-152), lists ten essential health benefits (EHBs) which health care service plans (health plans) and individual or group health insurers (insurers) must provide beginning in 2014.
In March 2010, the federal government passed the ACA, which includes a number of provisions that would directly and indirectly prompt changes in health care delivery, finance, and coverage, and that would affect benefits covered by California health insurance products. Specifically, the ACA includes provisions that require coverage for new federal benefit mandates. One of these mandates requires coverage of EHBs for most health insurance products sold in the individual and small-group markets, including the qualified health plans that will be sold through state health insurance exchanges. Under federal law, EHBs must include 10 general categories and the items and services covered within the categories are: a) Ambulatory patient services; b) Emergency services; c) Hospitalization; d) Maternity and newborn care; e) Mental health and substance use disorder services, including behavioral health treatment; f) Prescription drugs; g) Rehabilitative and habilitative services and devices; h) Laboratory services; i) Preventive and wellness services and chronic disease management; and, j) Pediatric services, including oral and vision care.
2011: On December 16, 2011, the Department of Health and Human Services (HHS) Center for Consumer Information and Insurance Oversight released an EHB Bulletin outlining a regulatory approach that HHS plans to propose to define EHBs. In the Bulletin, HHS proposed that EHBs be defined using a benchmark approach. States would have the flexibility to select a benchmark plan or model policy that reflects the scope of services offered by a "typical employer plan." EHBs would include coverage of services and items in all 10 statutory categories.
2012: In response to federal guidance regarding EHBs, the California legislature enacted Health and Safety Code section 1367.005 in September 2012. Health and Safety Code section 1367.005 selects the Kaiser Foundation Health Plan Small Group HMO 30 plan as California's base-benchmark plan and requires all Knox-Keene Act benefit mandates enacted on or before December 31, 2011 to be covered as part of the EHB-benchmark package. Mandated benefits included as EHBs are listed in Health and Safety Code section 1367.005(a)(2)(i) - (iv). Existing law at Health and Safety Code section 1367.005(a)(2)(v) requires that health plans cover as EHBs all "other health benefits" offered by the base-benchmark plan in the first quarter of 2012 in addition to state mandated benefits.
2013: 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.
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.
Robert Weiss, M.S.
Independent lymphedema patient advocate
December 6, 2013