Chapter 06-210

Chapter 210

2006 -- H 7020 AS AMENDED

Enacted 07/03/06

A N A C T

RELATING TO HEALTH INSURANCE COVERAGE -- ORTHOTIC AND PROSTHETIC SERVICES

Introduced By: Representatives Giannini, Moura, Gemma, Petrarca, and Rose

Date Introduced: February 01, 2006

It is enacted by the General Assembly as follows:

SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness

Insurance Policies" is hereby amended by adding thereto the following section:

27-18-67. Reimbursement for orthotic and prosthetic services. – (a) As used in this

section:

(1) "Federal reimbursement rates" means the current listed fee schedule from the Centers

for Medicare and Medicaid Services, listing the current Healthcare Common Procedure Coding

system (HCPCS) and the corresponding reimbursement rates.

(2) "Orthosis" means a custom fabricated brace or support that is designed based on

medical necessity. Orthosis does not include prefabricated or direct-formed orthotic devices, as

defined in this section, or any of the following assistive technology devices: commercially

available knee orthoses used following injury or surgery; spastic muscle-tone inhibiting orthoses;

upper extremity adaptive equipment; finger splints; hand splints; wrist gauntlets; face masks used

following burns; wheelchair seating that is an integral part of the wheelchair and not worn by the

patient independent of the wheelchair; fabric or elastic supports; corsets; low-temperature formed

plastic splints; trusses; elastic hose; canes; crutches; cervical collars; dental appliances; and other

similar devices as determined by the director of the department of health, such as those

commonly carried in stock by a pharmacy, department store, corset shop, or surgical supply

facility.

(3) "Orthotics" means the science and practice of evaluating measuring, designing,

fabricating, assembling, fitting, adjusting or servicing, as well as providing the initial training

necessary to accomplish the fitting of, an orthosis for the support, correction, or alleviation of

neuromuscular or musculoskeletal dysfunction, disease, injury or deformity. The practice of

orthotics encompasses evaluation, treatment, and consultation; with basic observational gait and

postural analysis, orthotists assess and design orthoses to maximize function and provide not only

the support but the alignment necessary to either prevent or correct a deformity or to improve the

safety and efficiency of mobility or locomotion or both. Orthotic practice includes providing

continuing patient care in order to assess its effect on the patient's tissues and to assure proper fit

and function of the orthotic device by periodic evaluation.

(4) "Prosthesis" means an artificial limb that is alignable or, in lower-extremity

applications capable of weight bearing. Prosthesis means an artificial medical device that is not

surgically implanted and that is used to replace a missing limb, appendage, or other external

human body part including an artificial limb, hand, or foot. The term does not include artificial

eyes, ears, noses, dental appliances, osotmy products, or devices such as eyelashes or wigs.

(5) "Prosthetics" means the science and practice of evaluation, measuring, designing,

fabricating, assembling, fitting, aligning, adjusting or servicing, as well as providing the initial

training necessary to accomplish the fitting of, a prosthesis through the replacement of external

parts of a human body lost due to amputation or congenital deformities or absences. The practice

of prosthetics also includes the generation of an image, form, or mold that replicates the patient's

body or body segment and that requires rectification of dimensions, contours and volumes for use

in the design and fabrication of a socket to accept a residual anatomic limb to, in turn, create an

artificial appendage that is designed either to support body weight or to improve or restore

function or cosmesis, or both. Involved in the practice of prosthetics is observational gait analysis

and clinical assessment of the requirements necessary to refine and mechanically fix the relative

position of various parts of the prosthesis to maximize function, stability, and safety of the

patient. The practice of prosthetics includes providing and continuing patient care in order to

assess the prosthetic device's effect on the patient's tissues and to assure proper fit and function of

the prosthetic device by periodic evaluation.

(6) "Private insurance company" means any insurance company, or management

company hired by an insurance company, who is any of the following:

(i) based in the state of Rhode Island; or

(ii) provides coverage for citizens for the state of Rhode Island; or

(iii) allows subscribing patients to seek prosthetic or orthotic services in the state of

Rhode Island.

(b) Every individual or group health insurance contract, plan or policy delivered, issued

for delivery or renewed in this state on or after January 1, 2006, which provides medical coverage

that includes coverage for physician services in a physician's office and every policy, which

provides major medical or similar comprehensive type coverage shall provide coverage for

benefits for orthotic and prosthetic devices that equal those benefits provided for under federal

laws for health insurance for the aged and disabled pursuant to 42 U.S.C. sections 1395K, 13951

and 1395M and 42 CFR 414.202, 414.210, 414.228, and 410.100 as applicable to this section.

and prosthetic devices in the same manner that prior authorization is required for any other

covered benefit.

(d) Covered benefits for orthotic or prosthetic devices shall be limited to the most

appropriate model that adequately meets the medical needs of the patient as determined by the

insured's treating physician.

(e) The repair and replacement of orthotic or prosthetic devices also shall be covered

subject to co-payments and deductibles, unless necessitated by misuse or loss.

(f) An insurer may require, if coverage is provided through a managed care plan, that

benefits mandated pursuant to this section be covered benefits only if the orthotic or prosthetic

devices are provided by a vendor and orthotic or prosthetic services are rendered by a provider

who is licensed by the state of Rhode Island to provide orthotics and prosthetics.

(g) This chapter shall not apply to insurance coverage providing benefits for: (1) Hospital

confinement indemnity; (2) Disability income; (3) Accident only; (4) Long-term care; (5)

Medicare supplement; (6) Limited benefit health; (7) Specified disease indemnity; (8) Sickness or

bodily injury or death by accident or both; and (9) Other limited benefit policies.

SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

Corporations" is hereby amended by adding thereto the following section:

27-19-58. Reimbursement for orthotics and prosthetic services. – (a) As used in this