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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.




Legislative Review Note
    as of 1-5-09 3:54 PM


Office of Legislative Research and General Counsel


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