Section 4315 - Coverage of prosthetic devices1. Definition. As used in this section, "prosthetic device" means an artificial device to replace, in whole or in part, an arm or a leg. [2003, c. 459, §1(NEW); 2003, c. 459, §2(AFF).]
2.Required coverage. A carrier shall provide coverage for prosthetic devices in all health plans that, at a minimum, equals, except as provided in subsection 8, the coverage and payment for prosthetic devices provided under federal laws and regulations for the aged and disabled pursuant to 42 United States Code, Sections 1395k, 1395l and 1395m and 42 Code of Federal Regulations, Sections 414.202, 414.210, 414.228 and 410.100. Covered benefits must be provided for: A. A prosthetic device determined by the enrollee's provider, in accordance with section 4301-A, subsection 10-A, to be the most appropriate model that adequately meets the medical needs of the enrollee; and [2021, c. 741, §1(NEW).]B. With respect to an enrollee under 18 years of age, in addition to coverage of a prosthetic device required by paragraph A, a prosthetic device determined by the enrollee's provider, in accordance with section 4301-A, subsection 10-A, to be the most appropriate model that meets the medical needs of the enrollee for recreational purposes, as applicable, to maximize the enrollees ability to ambulate, run, bike and swim and to maximize upper limb function. [2021, c. 741, §1(NEW).] [2021, c. 741, §1(AMD).]
3.Prior authorization. A carrier may require prior authorization for prosthetic devices in the same manner as prior authorization is required for any other covered benefit. [2003, c. 459, §1(NEW); 2003, c. 459, §2(AFF).]
4.Repair or replacement. Coverage under this section must also be provided for repair or replacement of a prosthetic device if repair or replacement is determined appropriate by the enrollee's provider. [2003, c. 459, §1(NEW); 2003, c. 459, §2(AFF).]
5.Coverage under managed care plan. If coverage under this section is provided through a managed care plan, a carrier may require that prosthetic services be rendered by a provider who contracts with the carrier and that a prosthetic device be provided by a vendor designated by the carrier. [2003, c. 459, §1(NEW); 2003, c. 459, §2(AFF).]
6. Exclusions. Except as provided in subsection 2, paragraph B for an enrollee under 18 years of age, coverage is not required pursuant to this section for a prosthetic device that is designed exclusively for an athletic purpose. [2021, c. 741, §2(AMD).]
7.Application. The requirements of this section apply to all individual and group policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State. For purposes of this section, all contracts are deemed to be renewed no later than the next yearly anniversary of the contract date. [2003, c. 517, Pt. B, §34(NEW).]
8.Health savings accounts. Benefits for prosthetic devices under health plans issued for use in connection with health savings accounts as authorized under Title XII of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 may be subject to the same deductibles and out-of-pocket limits that apply to overall benefits under the contract. [2003, c. 688, Pt. I, §2(NEW).]
9.Report. No later than June 30, 2028, each carrier that issues a health plan subject to this section shall report to the superintendent on its experience pursuant to this section for plan years 2024, 2025, 2026 and 2027. The report must be in a form prescribed by the superintendent and must include the number of claims and the total amount of claims paid in this State for the services required by this section. The superintendent shall aggregate this data by plan year in a report and submit the report to the joint standing committee of the Legislature having jurisdiction over health coverage and insurance matters no later than November 1, 2028. [2021, c. 741, §3(NEW).]
Amended by 2022, c. 741,§ 3, eff. 8/8/2022, app. to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after 1/1/2024.Amended by 2022, c. 741,§ 2, eff. 8/8/2022, app. to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after 1/1/2024.Amended by 2022, c. 741,§ 1, eff. 8/8/2022, app. to all policies, contracts and certificates executed, delivered, issued for delivery, continued or renewed in this State on or after 1/1/2024.2003, c. 459, § 1 (NEW) . 2003, c. 459, § 2 (AFF) . 2003, c. 517, §B34 (AMD) . 2003, c. 688, §§I1,2 (AMD) . 2009, c. 603, § 1 (AMD) . 2009, c. 603, § 2 (AFF) .