Academy Comments on Essential Health Benefits before Health and Human Services


Academy comments on Essential Health Benefits
Presented at the
HHS Essential Health Benefits Providers Session
Tuesday, October 18, 2011
By Peter D. Rosenstein, Executive Director
American Academy of Orthotists and Prosthetists


On behalf of the American Academy of Orthotists and Prosthetists (the Academy), the professional organization representing those allied health professionals trained and certified to provide orthotic and prosthetic care, I appreciate the opportunity to discuss the need to specifically name orthotics and prosthetics as an essential health service within the "Essential Benefits Package" of the Patient Protection and Affordable Care Act of 2010.

As you consider which benefits will be covered and balance coverage and cost as suggested by the Institute of Medicine report, I think it is crucial to not only determine the cost of providing a particular benefit but the added cost to society of not providing it. This is particularly relevant when you consider the care and services needed by those with either a disability or chronic disease.

One of the legislation’s broad categories defined in the ‘essential benefits package’ section is rehabilitative and habilitative services and devices. The Academy believes that, for the benefit of the patients we serve, orthotics and prosthetics must be named as specifically covered within this category.

We share the view of Congressman George Miller (D-CA), who has stated, “I believe that the legislative history supports the interpretation that Congress did mean to include needed orthotics and prosthetics in what was covered. I am pleased that the essential benefits in the Patient Protection and Affordable Care Act include rehabilitative and habilitative devices, as these benefits are of particular importance to people with disabilities and chronic conditions. The term ‘rehabilitative and habilitative devices’ includes durable medical equipment, prosthetics, orthotics, and related supplies.” He went on to say, “It is my understanding that the Secretary of HHS is required to develop, through regulation, standard definitions of many terms for purposes of comparing benefit categories from one private health plan to another and it is my expectation prosthetics, orthotics and related supplies will be defined separately from ‘durable medical equipment.’”

The Academy believes it important to point out that people with a disability or chronic disease, or those who have a family member who is sick or disabled, often don’t find out that the care they require may not be covered in their particular insurance plan until they try to obtain this needed care. While most plans do cover these services and devices, it is crucial that the unique care provided by appropriately certified orthotists and prosthetists is clearly stated as covered within all policies as an “essential benefit.”

Senator Ted Kennedy (D-MA) began his fight for health insurance partially because when his son lost a leg to cancer, he realized that many parents in similar situations faced serious issues and costs because their children were not covered for the cost of a prosthetic under their plans. Or, if they were covered, often a cap was placed on this coverage, which meant potentially only partial coverage for one prosthetic limb although their child would require replacements as they grew and matured. Senator Kennedy understood that this was unacceptable.

He understood the cost to society if his child, or any person who needed this type of service and device, were not able to support themselves and their families and to live productive and full lives. The Academy shares his view and his understanding that the cost of providing this appropriate care is miniscule when compared to the cost to society and the individual of not providing it.

We respectfully ask that the Department of Health and Human Services make a determination that appropriate orthotic and prosthetic care, including services and devices, be determined to be and included as an essential health benefit.