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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XXII CORPORATIONS
  • CHAPTER 175 INSURANCE
  • Section 47Z Coverage for prosthetic devices and repairs

Section 47Z. (a) Any blanket or general policy of insurance, except a blanket or general policy of insurance which provides supplemental coverage to Medicare or other governmental programs, described in subdivision (A), (C) or (D) of section 110 which provides hospital expense and surgical expense insurance and which is issued or subsequently renewed by agreement between the insurer and the policy holder, within or without the commonwealth, during the period this section is effective, or any policy of accident or sickness insurance as described in section 108 which provides hospital expense and surgical expense insurance, except a policy which provides supplemental coverage to Medicare or other governmental programs, and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policy holder in the commonwealth, during the period that this section is effective, or any employees’ health and welfare fund which provides hospital expense and surgical expense benefits and which is promulgated or renewed to any person or group of persons in the commonwealth, while this section is effective, shall provide coverage for prosthetic devices and repairs under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section.

(b) In this section, “prosthetic device” shall mean an artificial limb device to replace, in whole or in part, an arm or leg.

(c) No such policy shall impose any annual or lifetime dollar maximum on coverage for prosthetic devices other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the policy.

(d) No such policy shall apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the policy other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the policy.

(e) Any such policy may include a reasonable coinsurance requirement for prosthetic devices and repairs, not to exceed 20 per cent of the allowable cost of the prosthetic device or repair, unless all covered benefits applying coinsurance under the plan do so at a higher amount. If such policy provides coverage for services from nonparticipating providers, the contract may include a reasonable coinsurance requirement for prosthetic devices and repairs, not to exceed 40 per cent of the allowable cost of the device or repair when obtained from a nonparticipating provider, unless all covered benefits applying coinsurance under the plan do so at a higher amount.

(f) Any such policy may require prior authorization as a condition of coverage for prosthetic devices.

(g) Any such policy shall only be required to provide coverage for the most appropriately medically necessary model that adequately meets the needs of the policyholder.