H.B. 89

This document includes House Committee Amendments incorporated into the bill on Fri, Feb 20, 2009 at 3:47 PM by ddonat. --> 1

PROSTHETIC LIMB HEALTH INSURANCE
2 PARITY
3 2009 GENERAL SESSION
4 STATE OF UTAH
5 Chief Sponsor: David Litvack
6 Senate Sponsor: John L. Valentine
7
8 LONG TITLE
9 General Description:
10 This bill amends the Insurance Code to require H. [ accident and health insurers ] a health
10a benefit plan .H to provide
11 coverage for prosthetic devices.
12 Highlighted Provisions:
13 This bill:
14 . defines terms;
15 . requires H. [ accident and health insurers ] a health benefit plan .H to provide
15a coverage for prosthetic devices; and
16 . establishes the terms of coverage and the minimum requirements for access to
17 providers.
18 Monies Appropriated in this Bill:
19 None
20 Other Special Clauses:
21 None
22 Utah Code Sections Affected:
23 ENACTS:
24 31A-22-636, Utah Code Annotated 1953
25
26 Be it enacted by the Legislature of the state of Utah:
27 Section 1. Section 31A-22-636 is enacted to read:

28 31A-22-636. Coverage for prosthetic devices.
29 (1) For purposes of this section:
30 (a) "Orthotic device" means a rigid or semirigid device supporting a weak or deformed
31 leg, foot, arm, hand, back, or neck, or restricting or eliminating motion in a diseased or injured
32 leg, foot, arm, hand, back, or neck.
33 (b) (i) "Prosthetic device" means an artificial limb device or appliance designed to
34 replace in whole or in part an arm or a leg.
35 (ii) "Prosthetic device" does not include an orthotic device.
36 (2) Beginning July 1, 2009, H. [ an accident and health insurance policy that provides
37 coverage for hospital, medical, or surgical expenses ] health benefit plan .H shall provide coverage
37a for benefits for
38 H. [ prosthetics ] prosthetic devices .H that:
39 (a) at a minimum, equals the coverage provided for under the federal Medicare
40 program pursuant to 42 U.S.C. Secs. 1395k, 1395l, and 1395m and 42 C.F.R 414.202, 414.210,
41 and 414.228 as applicable to this section; and
42 (b) includes:
43 (i) all services and supplies necessary for the effective use of a prosthetic device,
44 including:
45 (A) formulating its design;
46 (B) fabrication;
47 (C) material and component selection;
48 (D) measurements and fittings;
49 (E) static and dynamic alignments; and
50 (F) instructing the patient in the use of the device;
51 (ii) all materials and components necessary to use the device; and
52 (iii) any repair or replacement of a prosthetic device that is determined medically
53 necessary to restore or maintain the ability to complete activities of daily living or essential
54 job-related activities and that is not solely for comfort or convenience.
55 (3) The coverage required by this section:
56 (a) may H. , except as otherwise provided in this section .H be made subject to H. [ ,
56a and no more restrictive than, the provisions of an accident
57 and health insurance policy that apply to other benefits under the policy ] cost-sharing provisions,
57a including dollar limits, deductibles, and coinsurance, that are not less favorable to the insured
57b than the cost-sharing provisions of the health benefit plan that apply to physical illness
57c generally .H ;
58 (b) may impose a copayment and coinsurance amounts on a prosthetic device, not to

59 exceed the copayment or coinsurance amounts imposed under Part B of the Medicare
60 fee-for-service program; H. and .H
61 (c) shall reimburse for a prosthetic device at no less than the fee schedule amount for
62 the prosthetic device under the federal Medicare reimbursement schedule H. [ ;
63 (d) may not impose any annual or lifetime dollar maximum on coverage for prosthetic
64 devices other than an annual or lifetime dollar maximum that applies in the aggregate to all
65 terms and services covered under the policy; and
66 (e) does not apply to a policy that provides benefits solely for:
67 (i) accident only coverage;
68 (ii) a specific disease;
69 (iii) hospital indemnity;
70 (iv) Medicare supplement;
71 (v) long-term care;
72 (vi) disability income replacement;
73 (vii) dental;
74 (viii) vision; or
75 (ix) a limited health plan offered under Chapter 8, Health Maintenance Organizations
76 and Limited Health Plans ] .H .
77 (4) If coverage is provided through a managed care plan, offered under Chapter 8,
78 Health Maintenance Organizations and Limited Health Plans, or under a preferred provider
79 plan under this chapter, the insured shall have access to medically necessary clinical care and to
80 prosthetic devices and technology from not less than two distinct Utah prosthetic providers in
81 the managed care plan's provider network.




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as of 1-5-09 3:54 PM

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