Coverage for Activity-Specific Prosthetic and Orthotic Devices

What You Need to Know

Historically, prosthetic and orthotic devices specifically made for physical activity, sports, and exercise were not covered by insurance. Although exercise and physical activity are viewed as an integral part of everyday life by the general public, insurance companies often consider a second, activity-specific prosthesis/orthosis not medically necessary. In 2022, AOPA, NAAOP, AAOP, and the Amputee Coalition joined in collaboration to start a national policy and advocacy initiative called So Kids Can Move. The focus of the initiative is to clarify that activity-specific orthotic and prosthetic devices allow individuals with limb loss and limb difference to participate in exercise, recreation, and physical activities, which IS medically necessary to remain healthy and functional.  As legislation efforts grew across the country, many states expanded the focus to include both children and adults, prompting the name change to So Every BODY Can Move. Advocates continue to work together to create and present bills to their state legislature, which require coverage for activity-specific prosthetic and orthotic devices. 

Currently, there are 5 states with enacted legislation. The laws in Maine, Arkansas, and New Mexico are already in effect, while Colorado and Illinois legislation have an effective date of January 1, 2025. There are also several other states involved in the initiative, including 10 states with bills already introduced to their state legislature, and 19 states working on a bill for the future. While all legislations include devices for physical activity, there are many other unique factors that may or may not be included in each state's bill. For example, a couple states also included coverage for showering/bathing devices. Some of the other differentiating factors include:

• Patient Age: 0-17, 0-18, or all ages
• Insurance Plans Affected: state commercial plans, state employee plans, and/or Medicaid
• Devices Covered: orthoses and/or prostheses

Many states that do not already have Insurance Fairness laws are also adding this language into their bill. Insurance Fairness, also known as O&P Parity, standardizes coverage for orthotic and prosthetic care by requiring that state-regulated commercial health insurance plans cover orthotic and prosthetic devices at a level that is at least equivalent to the coverage provided by the federal Medicare program. The So Every BODY Can Move initiative is using Insurance Fairness language as a foundation to clarify that medically necessary prosthetics and orthotics includes coverage of activity-specific prostheses and orthoses.

You can find more information about the states involved in this initiative and the terms of their legislation here.

What this Means for You

In less than two years, the So Every BODY Can Move initiative has grown to include advocates from 34 states. If your patient has insurance coverage in Maine, Arkansas, or New Mexico, they may already be eligible for an activity-specific device (or showering/bathing device), depending on the terms of their approved legislation. Coverage for these devices will continue to grow as more bills are introduced and approved in other states across the country. It is important to stay up to date with the legislation in your state to ensure that you are aware of your patients' rights for coverage of activity-specific prostheses and orthoses. You should also discuss the initiative directly with your patients to help them understand how it might affect their ability to obtain insurance coverage for these devices in the future.

Along with recognizing if/when the law is effective, you also need to understand what is included in your state's bill. Having a complete understanding of the included terms and conditions, such as patient age, insurance plans, and types of devices, allows you to determine which of your patients are/will be affected by the approved legislation. Furthermore, insurance companies are likely to develop their own coverage criteria for activity-specific devices once legislation is approved and enacted. It is always important to review the medical policy for your patient's health plan to ensure that the coverage criteria are met and documented, along with medical necessity. If the medical policy does not address coverage for activity-specific devices and you receive a denial for services that should be covered based on new legislation, you should appeal the decision, referencing the applicable law(s) in your state. 

If you or your patients want more information or are interested in getting involved with So Every Body Can Move, you can fill out this form and/or visit their website.