NJ bill would make insurers cover artificial limbs for athletes. But some feel left out

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.

With experience surfing at the Jersey Shore, the 11-year-old from Paramus had few issues navigating the mall's indoor water park at the Challenged Athletes' Foundation surf clinic − even with a prosthetic leg. DiPersia's left leg was amputated below the knee when he was 13 months old.

He rode the waves using 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 DiPersia had grown out of his blade, and was waiting for a new one to be manufactured and fitted.

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"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 orthotics more accessible. While the measure fell short in the last legislative session, state Sen. Troy Singleton (D-Burlington) and Sen. Anthony M. Bucco (R-Morris/Somerset) re-introduced their bill in January.

First introduced in June, the bill, S3919, would require insurance coverage for an additional orthotic or prosthetic device "to engage in physical and recreational activities, including 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 Jan. 8, the last day of the 2023-24 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 from the insurance company is to deny − I don't have much patience for that."

Amputee movement around U.S.

Though most employer-sponsored and Affordable Care Act plans include “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 Part 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 manufacturers like Ossür 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 costs tens of thousands of dollars, none of which is covered.

“If the device(s) are determined 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 living," Hester said. "Medical equipment required exclusively for sports would not be covered by either program.”

More: Limb loss can make being active in New Jersey expensive. These resources can help

The insurance industry's Washington trade association, America's Health Insurance Plans, did not respond to messages 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?” asked Nicole Ver Kuilen, the American Orthotic and Prosthetic Association's public engagement manager. “Is it that I’m missing my foot? Or is it these outdated policies that keep me from being able to live an active life?”

Possibilities for expanded coverage

The bills to expand coverage were crafted 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 from the only disability that can limit physical activity. The proposed New Jersey legislation leaves out many other accommodations, including 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 to pay sighted human guides.

‘I can do more’: NJ kids with physical disabilities struggle to play, compete

"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 Jan. 8 fiscal note that it "does not know the actual number of covered individuals whose physicians will determine 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 means 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, Marmino carries "my 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 Montville. He is growing out of the specialized 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."

Jane Havsy is a storyteller for the Daily Record and DailyRecord.com, part of the USA TODAY Network. For full access to live scores, breaking news and analysis, subscribe today.

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This article originally appeared on Morristown Daily Record: NJ bill requires insurers to cover prostheses for disabled athletes