§4315. Coverage of prosthetic devices
1.
Definition.
As used in this section, "prosthetic device" means an artificial device to replace, in whole or in part, an arm or a leg.
[PL 2003, c. 459, §1 (NEW); PL 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 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.
[PL 2003, c. 688, Pt. I, §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.
[PL 2003, c. 459, §1 (NEW); PL 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.
[PL 2003, c. 459, §1 (NEW); PL 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.
[PL 2003, c. 459, §1 (NEW); PL 2003, c. 459, §2 (AFF).]
6.
Exclusions.
Coverage is not required pursuant to this section for a prosthetic device that is designed exclusively for athletic purposes.
[PL 2009, c. 603, §1 (AMD); PL 2009, c. 603, §2 (AFF).]
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.
[PL 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.
[PL 2003, c. 688, Pt. I, §2 (NEW).]
SECTION HISTORY
PL 2003, c. 459, §1 (NEW). PL 2003, c. 459, §2 (AFF). PL 2003, c. 517, §B34 (AMD). PL 2003, c. 688, §§I1,2 (AMD). PL 2009, c. 603, §1 (AMD). PL 2009, c. 603, §2 (AFF).