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Regulation and Compliance > State Regulation

Will your client’s PPACA plan cover that wheelchair?

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Some people with disabilities worry that health policymakers will look at what the Patient Protection and Affordable Care (Act) does to access for care for all sorts of other people, but not for them.

One area of concern is coverage for “durable medical equipment” (DME) — the wheelchairs, ramps, prosthetic limbs, hearing aids, insulin pumps and other items that may determine how well a person with a potentially disabling condition can get around, and work. In some cases, questions about access to the right kind of DME could determine whether your individual clients, or your benefits clients’ plan enrollees, end up living the lives they want to live, or being trapped on a couch watching TV.

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A team at the National Council on Disability (NCD) has reported on that concern in a newly released status report on how PPACA has affected people with disabilities.

The report is one of three PPACA-related reports the council has developed. The first report, which appeared last week, covers the implementation of PPACA provisions that affect people with disabilities. The third report, which is set to appear Feb. 2, will cover efforts to enforce compliance with PPACA provisions that affect people with disabilities.

The NCD team says it heard many complaints about PPACA public exchange websites that could not accommodate the needs of users with disabilities, and about exchange program “navigators,” or ombudsmen, who were not familiar with special health programs aimed at people with disabilities.

The team also heard complaints about the DME provisions in some states’ essential health benefits (EHB) package benchmarks. 

PPACA now requires issuers of individual and small-group plans in a state to offer benefits comparable to the benefits in the state’s EHB package.

In theory, EHB standards could improve coverage for people with disabilities.

In practice, some EHB standards “were written to accommodate policymakers’ desires to control costs,” not necessarily to maximize the well-being of people with disabilities, according to the NCD team.

One challenge is EHB limits on coverage for habilitative services, or services that help people born with limitations keep, learn, or improve functions for daily living, the NCD team says. Limitations on DME benefits are another concern, the team says.

Television commercials promoting DME to seniors have infuriated congressional budget cutters. Federal watchdog agencies have issued report after report on DME spending, and Medicare program managers have bragged about efforts to hold down DME costs.

See also: Medicare expands competitive bidding

The NCB team says the DME picture looks different from the perspective of people with disabilities than it does from the perspective of the budget cutters. 

Two interviewees told the NCB team that “current benefit problems are a continuation of covering only what is needed in the home instead of ‘what’s needed for life,’” the team says.

The team has included a long appendix that gives details on how different state EHB standards handle DME.

For a look at how three state EHB standards handle DME, read on.

A street in Hoboken, N.J.

1. New Jersey

New Jersey has a short definition that could lead to long battles over coverage.

DME “must be ordered by a network practitioner and arranged through the carrier,” according to the NCD team.

Preapproval is required. The NCB team had no information on when a New Jersey carrier might or might not be able to deny preapproval. 

See also: 3 DMEC absence management conversation starters

Image: Hoboken, N.J. (LHP/Allison Bell)

Kansas City, Mo., highway

2. Missouri

Missouri has a medium-long DME section in its EHB standard.

The Missouri DME provision includes items such as medical supplies, prosthetics and cochlear implants. The long list of exclusions includes exercise equipment, adhesive tape, doughnut cushions, hot packs, air conditioners and raised toilet seats.

The definition also excludes a tub chair that could be used in a shower, translift chairs and artificial heart implants.

See also: Insurers Grapple with Joplin Tornado Aftermath

Image: Kansas City, Mo. (LHP/Allison Bell) 

Mount Rainier, in Washington State

3. Washington state

Washington state is an example of a state with DME benefits provisions that may be easy for an insurance professional to understand: As far as the NCD could tell, it hasn’t written any down.

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