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COPA NEWS BRIEF July 31, 2007
C a l i f o r n i a O r t h o t i c s & P r o s t h e t i c s A s s o c at i
on
COPA-sponsored Assembly Bill 2012 went into effect on July 1, 2007. To comply
with this billīs provisions,
health insurance plans must make revisions to
their EOC/DFs, copayment summaries and benefits matrices to ensure that
the
benefit maximums for orthotics and prosthetics are the same as those for the
basic health care services, and that
the copayments, coinsurances, deductibles,
and out-ofpocket maximums are no more than the most common amounts applied
to
the basic health care services.
Under current California law, insurance plans are not allowed to
put into place
annual or lifetime benefits for "basic health care services." Because O&P
benefits must now be
treated as basic health care services, the imposition of
lifetime or annual caps on this benefit are no longer legal.
In addition to the removal of caps, copays for the O&P benefit are now limited
to those the patient would
normally experience for other basic health care
services. Copayments can not exceed what a patient would normally pay
for a
visit to a specialist or out of pocket for out patient surgery.
For patients with plans that are subject
to a deductible or if copayments for
those services accrue to an out-of-pocket maximum, then any enrollee cost-
sharing
for prosthetics or for orthotics may be subject to that same deductible
or accrue to the same out-of-pocket maximum.
In other words, if a patient has exceeded the planīs out of pocket expenses for
the enrollment time period, copayments
and deductibles no longer apply to the
O&P benefit. COPA is advising all of its members to carefully work with
patients
as plans revise their coverage to reflect the new law. Each plan may
structure the benefit according to the parameters
set by the patientīs existing
coverage for basic medical services, therefore plans will vary, with no set
maximum
for copays and deductibles as long as they are consistent with basic
medical services covered by the plan. COPA is also
advising its members to
consult with plan administrators to determine when and how often a co-pay must
be collected
for office visits. In order to assist its members through the
transition to the new law, COPA has added a FAQs section
on AB 2012 to its
website where common questions are answered as they arise.
Visit
<ww.oandp.com/copa>
for
more information. Or
COPA
236 W. Elm Avenue, Galt, CA
95632
209-744-2672
<ww.oandp.com/
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