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H.B. 66 Enrolled






Chief Sponsor: David Litvack

Senate Sponsor: John L. Valentine

             8      LONG TITLE
             9      General Description:
             10          This bill amends the Insurance Code to require an insurer that provides a health benefit
             11      plan to offer coverage for prosthetic devices.
             12      Highlighted Provisions:
             13          This bill:
             14          .    defines terms;
             15          .    requires an insurer that provides a health benefit plan to offer at least one plan that
             16      provides coverage for prosthetic devices; and
             17          .    establishes terms of coverage and minimum requirements relating to the coverage
             18      described in this bill.
             19      Monies Appropriated in this Bill:
             20          None
             21      Other Special Clauses:
             22          None
             23      Utah Code Sections Affected:
             24      ENACTS:
             25          31A-22-638, Utah Code Annotated 1953
             27      Be it enacted by the Legislature of the state of Utah:
             28          Section 1. Section 31A-22-638 is enacted to read:
             29          31A-22-638. Coverage for prosthetic devices.

             30          (1) For purposes of this section:
             31          (a) "Orthotic device" means a rigid or semirigid device supporting a weak or deformed
             32      leg, foot, arm, hand, back, or neck, or restricting or eliminating motion in a diseased or injured
             33      leg, foot, arm, hand, back, or neck.
             34          (b) (i) "Prosthetic device" means an artificial limb device or appliance designed to
             35      replace in whole or in part an arm or a leg.
             36          (ii) "Prosthetic device" does not include an orthotic device.
             37          (2) (a) Beginning January 1, 2011, an insurer, other than an insurer described in
             38      Subsection (2)(b), that provides a health benefit plan shall offer at least one plan, in each
             39      market where the insurer offers a health benefit plan, that provides coverage for benefits for
             40      prosthetics that includes:
             41          (i) a prosthetic device;
             42          (ii) all services and supplies necessary for the effective use of a prosthetic device,
             43      including:
             44          (A) formulating its design;
             45          (B) fabrication;
             46          (C) material and component selection;
             47          (D) measurements and fittings;
             48          (E) static and dynamic alignments; and
             49          (F) instructing the patient in the use of the prosthetic device;
             50          (iii) all materials and components necessary to use the prosthetic device; and
             51          (iv) any repair or replacement of a prosthetic device that is determined medically
             52      necessary to restore or maintain the ability to complete activities of daily living or essential
             53      job-related activities and that is not solely for comfort or convenience.
             54          (b) Beginning January 1, 2011, an insurer that is subject to Title 49, Chapter 20,
             55      Public Employees' Benefit and Insurance Program Act, shall offer to a covered employer at
             56      least one plan that:
             57          (i) provides coverage for prosthetics that complies with Subsections (2)(a)(i) through

             58      (iv); and
             59          (ii) requires an employee who elects to purchase the coverage described in Subsection
             60      (2)(b)(i) to pay an increased premium to pay the costs of obtaining that coverage.
             61          (c) At least one of the plans with the prosthetic benefits described in Subsections
             62      (2)(a) and (b) that is offered by an insurer described in this Subsection (2) shall have a
             63      coinsurance rate, that applies to physical injury generally and to prosthetics, of 80% to be paid
             64      by the insurer and 20% to be paid by the insured, if the prosthetic benefit is obtained from a
             65      person that the insurer contracts with or approves.
             66          (d) For policies issued on or after July 1, 2010 until July 1, 2015, an insurer is exempt
             67      from the 30% index rating restrictions in Section 31A-30-106.1 , and for the first year only that
             68      coverage under this section is chosen, the 15% annual adjustment restriction in Section
             69      31A-30-106.1 , for any small employer with 20 or less enrolled employees who chooses
             70      coverage that meets or exceeds the coverage under this section.
             71          (3) The coverage described in this section:
             72          (a) shall, except as otherwise provided in this section, be made subject to cost-sharing
             73      provisions, including dollar limits, deductibles, copayments, and co-insurance, that are not less
             74      favorable to the insured than the cost-sharing provisions of the health benefit plan that apply
             75      to physical illness generally; and
             76          (b) may limit coverage for the purchase, repair, or replacement of a microprocessor
             77      component for a prosthetic device to $30,000, per limb, every three years.
             78          (4) If the coverage described in this section is provided through a managed care plan,
             79      offered under Chapter 8, Health Maintenance Organizations and Limited Health Plans, or
             80      under a preferred provider plan under this chapter, the insured shall have access to medically
             81      necessary prosthetic clinical care, and to prosthetic devices and technology, from one or more
             82      prosthetic providers in the managed care plan's provider network.

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