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Second Substitute H.B. 66
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:
21 Other Special Clauses:
23 Utah Code Sections Affected:
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,
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, Public
55 Employees' Benefit and Insurance Program Act, shall offer to a covered employer at least one
56 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 (2)(a)
62 and (b) that is offered by an insurer described in this Subsection (2) shall have a coinsurance
63 rate, that applies to physical injury generally and to prosthetics, of 80% to be paid by the
64 insurer and 20% to be paid by the insured, if the prosthetic benefit is obtained from a person
65 that the insurer contracts with or approves.
66 (3) The coverage described in this section:
67 (a) shall, except as otherwise provided in this section, be made subject to cost-sharing
68 provisions, including dollar limits, deductibles, copayments, and co-insurance, that are not less
69 favorable to the insured than the cost-sharing provisions of the health benefit plan that apply to
70 physical illness generally; and
71 (b) may limit coverage for the purchase, repair, or replacement of a microprocessor
72 component for a prosthetic device to $50,000, per limb, every three years.
73 (4) If the coverage described in this section is provided through a managed care plan,
74 offered under Chapter 8, Health Maintenance Organizations and Limited Health Plans, or
75 under a preferred provider plan under this chapter, the insured shall have access to medically
76 necessary prosthetic clinical care, and to prosthetic devices and technology, from one or more
77 prosthetic providers in the managed care plan's provider network.
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