As ACA Repeal Vote Looms, O&P Issues Progress

The House continues to struggle to achieve enough votes within the Republican Party to repeal the Affordable Care Act (ACA) and replace it with the American Health Care Act (AHCA). Despite extensive pressure on Republican moderates, the House does not have enough votes at the present time to pass the bill and send it to the Senate for further consideration. Of greatest concern to House moderates is how the bill will impact those with pre-existing conditions and those who rely on Medicaid for their health care access. One of the biggest concerns for NAAOP is a recent amendment to the AHCA that would allow states to opt-out of providing Essential Health Benefits (EHB), which includes coverage for “rehabilitative services and devices.” This language is why the vast majority of ACA health plans and Medicaid expansion plans cover orthotics and prosthetics. NAAOP strongly supports continued access to O&P care in any bill passed by Congress on health reform.

As the ACA repeal debate continues, Medicare and other developments impact O&P:

  • Injured and Amputee Veterans Bill of Rights: NAAOP is working to reintroduce federal legislation to help educate veterans of their rights to obtain O&P care under the VA health care program. The bill seeks to make veterans aware of their right to select the practitioner of their choice and to obtain appropriate prosthetic technology that meets their needs. A new bipartisan bill is expected to be introduced soon.
  • Performant Audits: The nationwide Medicare Recovery Auditor for O&P claims (Performant) recently posted an approved issue on their website that signaled a new round of audits on knee stance flexion, HCPCS code L-5845, used with a wide variety of single axis knee codes. NAAOP and its O&P Alliance partners view the approval of this audit issue as a major overreach by Performant/CMS and have taken aggressive steps to oppose this issue and request withdrawal of this audit approval. The audit would change current Medicare coverage and coding guidance which RACs do not have authority to do. Progress is being made as Performant recently removed the audit announcement from its website without explanation.
  • LCD Legislation: In 2015, the DME MACs issued a draft Local Coverage Determination (LCD) for Lower Limb Prostheses (LLP) that would have dramatically restricted access to the current standard of O&P care. That draft LCD was placed on hold while CMS studies the issue through an Interagency Workgroup on LLP. That debacle has contributed to the reintroduction of legislation to change the LCD process. The Local Coverage Determination Clarification Act, S. 794, was recently introduced in the U.S. Senate and aims to make the LCD process more transparent and accountable. (A House bill is under development.) The bill requires public notice and comment and other processes to improve the development of LCDs, so experiences like the LLP draft LCD do not occur again. Special thanks to the Amputee Coalition for its leadership on this important bill. To send your two Senators an email encouraging them to cosponsor the legislation, go to the Congressional Action Center at www.NAAOP.org.
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  • Written by NAAOP in Update