My State Has A Parity Law; Now What?

By: Morgan Sheets, National Advocacy Director

There has been much cause to celebrate in recent months, as we have added four new states to the number that have passed laws ensuring access to prosthetic care – Arkansas, Iowa, Virginia and Maryland. However, while we are pleased with this progress in our national campaign for prosthetic coverage, as states enact these new laws, questions have been raised about the enforcement of the policies.

Which states have a parity law?

Parity laws have been signed into law in California, Colorado, Indiana, Maine, Massachusetts, New Hampshire, New Jersey, Oregon, Rhode Island, Vermont and Louisiana. Bill have been passed in Maryland, Virginia, Iowa and Arkansas. Campaigns are advancing in many other states.

What does it mean if my state has a parity law?

Each law differs in terms of the extent of coverage.

• Five of the laws (Colorado, Indiana, Rhode Island, Vermont, Iowa) say that the coverage for prosthetic care must at least meet Medicare standards (80 percent paid by plan, 20 percent by patient, no exemptions on microprocessor devices, 5-year useful lifetime limit).

• Ten of the laws (Maine, Massachusetts, New Hampshire, New Jersey, Oregon, Virginia Maryland, Arkansas, Louisiana, California) say that prosthetic coverage must be on par with other health services (no more or less restrictive). This means that the company cannot impose any limitations on prosthetic care that aren't also enforced for all other services.

• One of the laws (California) is a mandated offer. This means that instead of saying that a company must provide coverage, it says that if the plan provides coverage for prosthetic devices, then coverage must be on par with other health services (no more or less restrictive). This bill also applies to orthotic care.

• Five of the laws (Indiana, New Jersey, Oregon, Rhode Island, Arkansas) also include language regarding benefits for orthotics. Maryland includes coverage for orthopedic braces.

• Unfortunately, one of the laws (Maine) includes an exemption on microprocessor devices.

• One of the laws (Louisiana) includes a cap ($50,000 per limb, per year).
  

If I live in a parity state, what should I do if I am denied coverage?

You first need to determine if your state's insurance laws regulates your health plan.

• Certain health plans are exempt from state regulations. These are called ERISA (Employee Retirement Income Security Act of 1974) plans. This is a federal bill that sets minimum standards for health benefit plans in private industry. About 40-50 percent of health plans are federally regulated. This is one of the main reasons that the ACA is pushing for the federal parity bill (House Resolution 5615).

• Some companies or offices operate in one state but are headquartered in another state. If you live or work in one state but your company operates out of another state and your health insurance is managed out of state, your plan may not need to comply with the state parity law.

• Additionally, the laws don't generally include policies or plans providing coverage for a specific disease or other limited benefit coverage. For example, if you bought supplemental insurance specific to a certain condition or specifically for emergency services, it would not be covered under a parity bill. To determine your plan's eligibility, you should determine if it is regulated (a) at the state level and (b) within your state.

Where can I find out how my state's law applies to my insurance plan?

Talk to your human resources department or call the local office managing your health plan to determine if your plan is regulated under ERISA and therefore exempt from state law. You should also determine if your plan is managed in your state. Some states have their own regulations regarding satellite companies and enforcing state provisions. The state insurance administration is responsible for enforcing the regulations on health insurance in your state. They can answer specific questions regarding the enforcement of insurance provisions. You can find contact information for your state insurance department on a clickable map at www.naic.org/state_web_map.htm

What steps should I take to receive approval for my claim?

1) First, send a copy of your state's parity law to your health plan administrator, letting them know what the law says in your state. In many cases, this may actually result in an approval for your claim. You can easily find a copy of your state's parity law at www.amputee-coalition.org/advocacy/information

2) If you determine that your plan is indeed regulated under state law, you should pursue your claim directly with the insurance company. You should also contact your state insurance administration (www.naic.org/state_web_map.htm) to alert them to this enforcement issue.

3) You should also consider seeking assistance from your state's consumer protection office if your health insurance company isn't complying with the parity bill. You can find contact information for your consumer protection office at www.consumeraction.gov/state.shtml

The Amputee Coalition of America's (ACA's) National Limb Loss Information Center (NLLIC) has a whole set of helpful materials to assist you with an appeals process. You can reach them at 888/AMP-KNOW. The NLLIC also has an online form you can fill out to request information (www.amputee-coalition.org/forms/nllicask).

Do state parity laws apply to existing insurance policies or only new ones?

They apply to new and existing policies. For states with new bills, there is a period before the bill is enacted. For example, the New Jersey law was approved on January 13, 2008. It went into effect 90 days after enactment (April 13). Vermont was signed on April 23. It took effect on October 1, 2008, and shall apply to all health benefit plans on and after October 1, 2008, on such date as a health insurer offers, issues or renews the health benefit plan, but in no event later than October 1, 2009.

How do parity laws apply to Medicare?

State parity laws are specific to each respective state but they only apply to private insurance plans. They do not affect the coverage under government programs unless specifically noted (for example, New Jersey and Indiana added an amendment to include the state employee health benefits plan).

What if my state doesn't have a parity law?

There are a number of active campaigns in place to advance parity legislation. In addition, we are pushing for a bill in Congress. If you are interested in getting protections in place in your state, contact the ACA's advocacy department. Insurance regulations are complicated. This information should help to answer some of the questions you may have. We encourage you to contact the ACA if we can assist in any way. Together we will ensure that amputees get the care they need to lead independent, productive lives.

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The Amputee Coalition of America (ACA) is working hard to advance prosthetic coverage legislation at both the state and federal level. To learn more about our Congressional efforts, contact the ACA at federal@amputee-coalition.org or 202/742-1886. For more information about our work to shape policies at the state level, we can be reached at state@amputee-coalition.org or 202/742-1885.