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Separation of O&P from DME in Private Health Plans

On February 26, 2016, three federal agencies responsible for regulating the Affordable Care Act announced a proposal to add a new definition of the term “orthotics and prosthetics” to the “Uniform Glossary of Coverage and Medical Terms” (“Uniform Glossary”), separate and distinct from the definition of durable medical equipment (“DME”). This had been a goal of NAAOP as well as the O&P Alliance since 2008, even before passage of the ACA.

The Uniform Glossary is a collection of standard definitions of medical and insurance terms that assist individuals in understanding their private health insurance options. The document is written at an elementary level, so as to be understood by the vast majority of the public. Inclusion in the Uniform Glossary does not guarantee coverage of orthotic and prosthetic (O&P) services but it does help consumers understand what constitutes O&P coverage and assists them in comparing and contrasting levels of such coverage across competing health plans. It also formally signals separate treatment from durable medical equipment (DME) in private health plans.

A new definition of orthotics and prosthetics in the Uniform Glossary will stimulate consumers to ask questions about the extent of private plan coverage of O&P care. It can be used to argue that DME caps of one sort or another do not apply to orthotic and prosthetic services, and it may prompt health plans to collect better data on O&P benefits and better define coverage of this important benefit.

Orthotics and Prosthetics Definition The proposed regulation adopts a version of a definition that NAAOP and the Alliance recommended in numerous comment letters over the past six years, since enactment of the Affordable Care Act. The new definition of orthotics and prosthetics, as proposed in the Uniform Glossary, is as follows:

• Orthotics and Prosthetics: Leg, arm, back, and neck braces, and artificial legs, arms, and eyes, and external breast prostheses incident to mastectomy resulting from breast cancer. These services include: adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient’s physical condition.

Comments to this proposed definition are due on March 28, 2016, and NAAOP and the O&P Alliance will strongly support its adoption in the final Uniform Glossary. We may even offer some refinements to the definition, but the proposal to add this separate definition of orthotics and prosthetics is an important victory and should be strongly supported by the entire O&P profession and the larger rehabilitation and disability community. This will have an impact on all private insurance plans, not just ACA plans, and it will also strengthen the policy arguments for further separation of O&P from DME in both the Medicare and Medicaid programs.

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