The next wave for inclusion

Bill would make health insures cover artificial limbs for athletes

By: Jane Havsy
Morristown Daily Record
USA Today Network - New Jersey

..... His surfboard pursued by rolling white water, Gio DiPersia popped from his belly to his feet. His white T-shirt clung to his chest and his longish hair was plastered to his head as he rode an artificial wave toward the concrete beach at American Dream in East Rutherford last month. [02/2024]
..... With experience surfing at the Jersey Shore, the 11-year-old form Paramus had few issues navigating the mall's indoor water park at the Challenged Athletes Foundation surf clinic - even with a prosthetic leg. Gio's left leg was amputated below the knee when he was 13 months old.
..... He road the waves suing the artificial limb he uses for walking an unusual choice since the athletic middle schooler normally lives in a running blade more suited to sports. But Gio had grown out of his blade, and he was waiting for a new one to be manufactured and fitted.
..... "There's more flexibility. It's not stuck in the muck," he said of the specialized prosthesis, which his family has paid for over the years via grants from nonprofits.
..... The New Jersey Legislature is considering a bill that would make such activity-specific prostheses and orthodontics more accessible. After the measure fell short in the last legislative session, state Senator troy singleton, D-Burlington, and Anthony M. Bucco, R-Morris reintroduced their bill in January. [2024]
..... First introduced in June, [2023] the bill S3919, would require insurance coverage for an additional orthodontic or prosthetic device "to engage in physical and recreational activities, scudding running, bicycling, swimming, climbing, skiing, snowboarding and team and individual sports." The reimbursement rate would be the same as that used by the federal Medicare program.
..... The bill unanimously passed the Senate on January 8, 2024] the last day of the 2023-2024 legislative term. But it did not get out of committee in the Assembly."
..... "It's going to be hard for [insurance companies] to argue they shouldn't have to cover this," said Bucco, who survived thyroid cancer as a child and still goes for annual checkups at Memorial Sloan Kettering Cancer Center.
..... "The health insurance industry is something that I've dealt with a lot, being a cancer survivor, and watching folks deal with trying to get procedures or medications covered lately, where the first answer form the insurance companies is to deny - I don't have much patience for that," Bucco said.

Amputee movement around US

..... Though most employer-sponsored and Affordable Care Act plans including "medically necessary" prosthetic devices in their essential health benefits, that coverage is not universally available. Medicaid skips those benefits in states including Oklahoma, Texas and Mississippi. Medicare Parts B - which covers durable medical equipment, a category that includes canes and walkers as well as prostheses - requires patients to pay 20% of the cost, which is about $5,000 for a basic lower leg.
..... Levitate, a Copenhagen-based manufacturer, sells fiberglass running blades directly to consumers for about $2,000. Larger manufactures like Ossur can charge $3,500 for a basic below-the-knee foot and more than double that for an above-the-knee amputee.
..... But specialized equipment used by athletes to run, lift weights and do other physical activity cost tens of thousands of dollars, none of which is covered.
..... "If the device(s) are determine to be medically necessary based on a diagnosis by a doctor or other licensed practitioner, they can be covered. It's case-by-case depending on the situation," New Jersey Department of Human Services spokesman Tom Hester said via email.
..... "Medicaid and Medicare cover specialty equipment to support activities of daily lives," Hester said. "Medical equipment required exclusively for sports would not be covered by either programs."
..... The insurance industry's Washington trade association, America's Health Insurance Plans, did not respond to message seeking comment,
..... Five states - Maine, New Mexico, Arkansas, Colorado and Illinois - have added activity-specific prostheses to required insurance coverage. Advocacy efforts are underway in 20 more states, including New Jersey.
..... "What is it that makes me disabled?" Aisked Nicole Ver Kuilen, the American Orthodontic and Prosthetic Association's public engagement manager. "It it that I'm missing my foot? Or is it these outdated policies that keep me from being able to live an active life?"

Possible expanded coverage

..... The bills to expand coverage were craft by AOPA and are primarily focused on amputees and other people with limb loss. There are 1.9 million people with limb loss in the United states, according to Amputee Coalition, an advocacy group.
..... Yet that is far form the only disability that can limit physical activity. The proposed New Jersey legislation leaves out many other accommodation, indulging racing wheelchairs, specialized bicycles or guide dogs.
..... Melissa Blume, who was born with cataracts and other vision problems and is legally blind, would like help getting assistive technology for sports. She said people with vision loss want coverage for protective glasses, and even top pay sighted human guides.
..... "All services should cater to all people with disabilities, to everybody," Blume said at the surf clinic. "I do have some good usable vision, but I need technology to help me get around."
..... New Jersey;s Office of Legislative Services estimated that the Singleton-Bucco bill would require state and local governments to pay a combined $461,000 to $577,000 per year in additional expenses for employee health coverage. In the private insurance market, the analysis found the bill would increase health care premiums by just 0.025%.
..... The OLS admitted in its January 8 [2024] fiscal note that it :does not know the actual number of covered individuals whose physicians will determent that an additional prosthetic appliance is medically necessary to engage in physical recreational activities." But it estimated it would be half of all currently covered individuals.

Growing kids, growing costs

..... Anthony DiPersia, Gio's dad, is hoping for some sort of aid from the Legislature. While watching his son surf, he estimated that Gio outgrows at least one, and more often two, running blades each year.
..... Logan Marmino, a 13-year-old from Medford, is in the process of getting his sixth blade in as many years. During the middle school baseball season, Logan carries "mu bats and my legs into school" and stashes everything in the locker room.
..... The bill "makes a world of difference for kids, especially, to be more active," he said. "I wouldn't be able to compete in baseball or even play at all if I didn't have my running leg. It helps me to be more active, and able to compete with the other kids."
..... Another supporter is Alex Manna of Montiville. He is growing out of the specialize weightlifting hand he received from the Massachusetts-based Born to Run Foundation.
..... A Seton Hall Prep senior, Manna has used the prosthesis almost daily for the past two years - but it's too tight to easily slip on and off his residual forearm. Sometimes, the carbon-fiber hand would pop off during a heavy lift, and Manna would unexpectedly drop the weight.
..... "I don't see why insurance shouldn't cover it," Manna said. "You're paying money to be insured by them. You should have equal treatment."

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