Chapter
029
2007 -- S 0445 SUBSTITUTE A
Enacted 06/14/07
A N A C T
RELATING TO INSURANCE
-- ORTHOTIC AND PROSTHETIC SERVICES
Introduced By: Senators Ciccone, Badeau, Maselli, and Ruggerio
Date Introduced: February
13, 2007
It is enacted
by the General Assembly as follows:
SECTION
1. Chapter 27-41 of the General Laws entitled "Health Maintenance
Organizations"
is hereby amended by adding thereto the following section:
27-41-72.
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, 2008, 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.
(c)
A health insurance contract, plan or policy may require prior authorization for
orthotic
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 authorized 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 death by accident or both; and
(9)
other limited benefit policies.
SECTION
2. This act shall take effect upon passage.
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LC01854/SUB A
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