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Dedicated to Lymphedema Patients and the Therapists Who Treat Them

Lymphedema compression wraps and garments still covered in California by ACA. The California Department of Managed Health Care (Department) has updated its website giving notice of a proposed regulation, Essential Health Benefits, amending Title 28 of the California Code of Regulations. This change updates the existing § 1300.67.005 Essential Health Benefits regulation and maintains the coverage of lymphedema compression bandages and garments for insurance obtained under the Affordable Care Act (the Act). The following is an abstract of the proposed regulation:

(d) “Other health benefits” are essential health benefits and are required to be covered as follows:

(9) Prosthetic and orthotic services and devices in addition to those services and devices required to be covered under the Act.

  1. (A) Coverage includes fitting and adjustment of these devices, their repair or replacement (unless due to loss or misuse), and services to determine whether the enrollee needs a prosthetic or orthotic device. If the plan covers a replacement device, the enrollee pays the cost sharing the enrollee would pay for obtaining that device.
  2. (B) The plan shall cover the prosthetic and orthotic services and devices substantially equal to the following:
    1. (i) Enteral and Parenteral Nutrition: enteral formula and additives, adult and pediatric, including for inherited diseases of metabolism; enteral feeding supply kits; enteral nutrition infusion pump; enteral tubing; gastrostomy/jejunostomy tube and tubing adaptor; nasogastric tubing; parenteral nutrition infusion pump; parenteral nutrition solutions; stomach tube; and supplies for self-administered injections;
    2. (ii) Up to three brassieres required to hold a breast prosthesis every 12 months;
    3. (iii) Compression burn garments and lymphedema wraps and garments; and
    4. (iv) Prostheses to replace all or part of an external facial body part that has been removed or impaired as a result of disease, injury, or congenital defect.
      Open Pending Regulations

It is significant that the State of California recognizes that these lymphedema wraps and garments, when used in the compression therapy of lymphedema, meet the Medicare definition of “prosthetic devices”, a distinction yet to be understood by Medicare.