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Session Law

2006

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Chapter 292 AN ACT PROVIDING HEALTH CARE COVERAGE FOR CERTAIN PROSTHETIC DEVICES.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:

SECTION 1. Chapter 32A of the General Laws is hereby amended by inserting after section 17H the following section:-

Section 17I. (a) The commission shall provide coverage for prosthetic devices and repairs to any active or retired employee of the commonwealth who is insured under the group insurance commission 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) Such coverage shall not 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) Such coverage shall not 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) Such coverage 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 the policy provides coverage for services from nonparticipating providers, the policy 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) Such coverage may require prior authorization as a condition of coverage for prosthetic devices.

SECTION 2. Chapter 175 of the General Laws is hereby amended by inserting after section 47Y the following section:-

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.

SECTION 3. Chapter 176A of the General Laws is hereby amended by inserting after section 8Z the following section:-

Section 8AA. (a) A contract between a subscriber and the corporation under an individual or group hospital service plan which provides hospital expense and surgical expense insurance, except contracts providing supplemental coverage to Medicare or other governmental programs, delivered, issued or renewed by agreement between the insurer and the policyholder, within or without the commonwealth, shall provide benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the contract, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone benefit, coverage shall be consistent with the terms and conditions as described 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 contract 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 contract.

(d) No such contract 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 contract.

(e) Any such contract 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 the contract 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 prosthetic 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 contract may require prior authorization as a condition of coverage for prosthetic devices.

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

SECTION 4. Chapter 176B of the General Laws is hereby amended by inserting after section 4Z the following section:-

Section 4AA. (a) Any subscription certificate under an individual or group medical service agreement, except certificates which provide supplemental coverage to Medicare or other governmental programs that shall be delivered, issued or renewed within the commonwealth shall provide, as benefits to all individual subscribers or members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be consistent with the terms and conditions as described 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 certificate 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 certificate.

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

(e) Any such certificate 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 the certificate 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 prosthetic 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 certificate may require prior authorization as a condition of coverage for prosthetic devices.

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

SECTION 5. Chapter 176G of the General Laws is hereby amended by inserting after section 4R the following section:-

Section 4S. (a) Individual and group health maintenance contracts shall provide coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the contracts, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be consistent with the terms and conditions as described 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) A health maintenance contract shall not 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 contract.

(d) A health maintenance contract shall not apply amounts paid for prosthetic devices to any annual or lifetime dollar maximum applicable to other durable medical equipment covered under the contract other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the contract.

(e) A health maintenance contract 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 the health maintenance contract 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 prosthetic 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) A health maintenance contract may require prior authorization as a condition of coverage for prosthetic devices.

(g) A health maintenance contract shall only be required to provide coverage for the most appropriate medically necessary model that adequately meets the medical needs of the policyholder.

SECTION 6. This act shall apply to all policies, contracts, agreements, plans or certificates of insurance issued or delivered within the commonwealth on or after January 1, 2007, or upon renewal to all policies, contracts, agreements, plans or certificates of insurance in effect before January 1, 2007.

Approved September 7, 2006.


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