2006 -- S 2176

=======

LC00756

=======

STATE OF RHODE ISLAND

IN GENERAL ASSEMBLY

JANUARY SESSION, A.D. 2006

____________

A N A C T

RELATING TO HEALTH INSURANCE COVERAGE -- ORTHOTIC AND PROSTHETIC

SERVICES

     

     

     Introduced By: Senators Ciccone, Badeau, McCaffrey, Alves, and Pichardo

     Date Introduced: January 26, 2006

     Referred To: Senate Health & Human Services

It is enacted by the General Assembly as follows:

1-1

     SECTION 1. Chapter 27-18 of the General Laws entitled "Accident and Sickness

1-2

Insurance Policies" is hereby amended by adding thereto the following section:

1-3

     27-18-65. Reimbursement for orthotic and prosthetic services. (a) As used in this

1-4

section:

1-5

     (1) "Federal reimbursement rates" means the current listed fee schedule from the Centers

1-6

for Medicare and Medicaid Services, listing the current Healthcare Common Procedure Coding

1-7

system (HCPCS) and the corresponding reimbursement rates.

1-8

     (2) "Orthosis" means a custom fabricated brace or support that is designed based on

1-9

medical necessity. Orthosis does not include prefabricated or direct-formed orthotic devices, as

1-10

defined in this section, or any of the following assistive technology devices: commercially

1-11

available knee orthoses used following injury or surgery; spastic muscle-tone inhibiting orthoses;

1-12

upper extremity adaptive equipment; finger splints; hand splints; wrist gauntlets; face masks used

1-13

following burns; wheelchair seating that is an integral part of the wheelchair and not worn by the

1-14

patient independent of the wheelchair; fabric or elastic supports; corsets; low-temperature formed

1-15

plastic splints; trusses; elastic hose; canes; crutches; cervical collars; dental appliances; and other

1-16

similar devices as determined by the director of the department of health, such as those

1-17

commonly carried in stock by a pharmacy, department store, corset shop, or surgical supply

1-18

facility.

2-1

     (3) "Orthotics" means the science and practice of evaluating measuring, designing,

2-2

fabricating, assembling, fitting, adjusting or servicing, as well as providing the initial training

2-3

necessary to accomplish the fitting of, an orthosis for the support, correction, or alleviation of

2-4

neuromuscular or musculoskeletal dysfunction, disease, injury or deformity. The practice of

2-5

orthotics encompasses evaluation, treatment, and consultation; with basic observational gait and

2-6

postural analysis, orthotists assess and design orthoses to maximize function and provide not only

2-7

the support but the alignment necessary to either prevent or correct a deformity or to improve the

2-8

safety and efficiency of mobility or locomotion or both. Orthotic practice includes providing

2-9

continuing patient care in order to assess its effect on the patient's tissues and to assure proper fit

2-10

and function of the orthotic device by periodic evaluation.

2-11

     (4) "Prosthesis" means an artificial limb that is alignable or, in lower-extremity

2-12

applications capable of weight bearing. Prosthesis means an artificial medical device that is not

2-13

surgically implanted and that is used to replace a missing limb, appendage, or other external

2-14

human body part including an artificial limb, hand, or foot. The term does not include artificial

2-15

eyes, ears, noses, dental appliances, osotmy products, or devices such as eyelashes or wigs.

2-16

     (5) "Prosthetics" means the science and practice of evaluation, measuring, designing,

2-17

fabricating, assembling, fitting, aligning, adjusting or servicing, as well as providing the initial

2-18

training necessary to accomplish the fitting of, a prosthesis through the replacement of external

2-19

parts of a human body lost due to amputation or congenital deformities or absences. The practice

2-20

of prosthetics also includes the generation of an image, form, or mold that replicates the patient's

2-21

body or body segment and that requires rectification of dimensions, contours and volumes for use

2-22

in the design and fabrication of a socket to accept a residual anatomic limb to, in turn, create an

2-23

artificial appendage that is designed either to support body weight or to improve or restore

2-24

function or cosmesis, or both. Involved in the practice of prosthetics is observational gait analysis

2-25

and clinical assessment of the requirements necessary to refine and mechanically fix the relative

2-26

position of various parts of the prosthesis to maximize function, stability, and safety of the

2-27

patient. The practice of prosthetics includes providing and continuing patient care in order to

2-28

assess the prosthetic device's effect on the patient's tissues and to assure proper fit and function of

2-29

the prosthetic device by periodic evaluation.

2-30

     (6) "Private insurance company" means any insurance company, or management

2-31

company hired by an insurance company, who is any of the following:

2-32

     (i) based in the state of Rhode Island; or

2-33

     (ii) provides coverage for citizens for the state of Rhode Island; or

2-34

      (iii) allows subscribing patients to seek prosthetic or orthotic services in the state of

3-1

Rhode Island.

3-2

     (b) Every individual or group health insurance contract, plan or policy delivered, issued

3-3

for delivery or renewed in this state on or after January 1, 2006, which provides medical coverage

3-4

that includes coverage for physician services in a physician's office and every policy, which

3-5

provides major medical or similar comprehensive type coverage shall provide coverage for

3-6

benefits for orthotic and prosthetic devices that equal those benefits provided for under federal

3-7

laws for health insurance for the aged and disabled pursuant to 42 U.S.C. sections 1395K, 13951

3-8

and 1395M and 42 CFR 414.202, 414.210, 414.228, and 410.100 as applicable to this section.

3-9

     (c) A health insurance contract, plan or policy may require prior authorization for orthotic

3-10

and prosthetic devices in the same manner that prior authorization is required for any other

3-11

covered benefit.

3-12

     (d) Covered benefits for orthotic or prosthetic devices shall be limited to the most

3-13

appropriate model that adequately meets the medical needs of the patient as determined by the

3-14

insured's treating physician.

3-15

     (e) The repair and replacement of orthotic or prosthetic devices also shall be covered

3-16

subject to co-payments and deductibles, unless necessitated by misuse or loss.

3-17

     (f) An insurer may require, if coverage is provided through a managed care plan, that

3-18

benefits mandated pursuant to this section be covered benefits only if the orthotic or prosthetic

3-19

devices are provided by a vendor and orthotic or prosthetic services are rendered by a provider

3-20

who is licensed by the state of Rhode Island to provide orthotics and prosthetics.

3-21

     SECTION 2. Chapter 27-19 of the General Laws entitled "Nonprofit Hospital Service

3-22

Corporations" is hereby amended by adding thereto the following section:

3-23

     27-19-56. Reimbursement for orthotics and prosthetic services. (a) As used in this

3-24

section:

3-25

     (1) "Federal reimbursement rates" means the current listed fee schedule from the Centers

3-26

for Medicare and Medicaid Services, listing the current Healthcare Common Procedure Coding

3-27

system (HCPCS) and the corresponding reimbursement rates.

3-28

     (2) "Orthosis" means a custom fabricated brace or support that is designed based on

3-29

medical necessity. Orthosis does not include prefabricated or direct-formed orthotic devices, as

3-30

defined in this section, or any of the following assistive technology devices: commercially

3-31

available knee orthoses used following injury or surgery; spastic muscle-tone inhibiting orthoses;

3-32

upper extremity adaptive equipment; finger splints; hand splints; wrist gauntlets; face masks used

3-33

following burns; wheelchair seating that is an integral part of the wheelchair and not worn by the

3-34

patient independent of the wheelchair; fabric or elastic supports; corsets; low-temperature formed

4-1

plastic splints; trusses; elastic hose; canes; crutches; cervical collars; dental appliances; and other

4-2

similar devices as determined by the director of the department of health, such as those

4-3

commonly carried in stock by a pharmacy, department store, corset shop, or surgical supply

4-4

facility.

4-5

     (3) "Orthotics" means the science and practice of evaluating measuring, designing,

4-6

fabricating, assembling, fitting, adjusting or servicing, as well as providing the initial training

4-7

necessary to accomplish the fitting of, an orthosis for the support, correction, or alleviation of

4-8

neuromuscular or musculoskeletal dysfunction, disease, injury or deformity. The practice of

4-9

orthotics encompasses evaluation, treatment, and consultation; with basic observational gait and

4-10

postural analysis, orthotists assess and design orthoses to maximize function and provide not only

4-11

the support but the alignment necessary to either prevent or correct a deformity or to improve the

4-12

safety and efficiency of mobility or locomotion or both. Orthotic practice includes providing

4-13

continuing patient care in order to assess its effect on the patient's tissues and to assure proper fit

4-14

and function of the orthotic device by periodic evaluation.

4-15

     (4) "Prosthesis" means an artificial limb that is alignable or, in lower-extremity

4-16

applications capable of weight bearing. Prosthesis means an artificial medical device that is not

4-17

surgically implanted and that is used to replace a missing limb, appendage, or other external

4-18

human body part including an artificial limb, hand, or foot. The term does not include artificial

4-19

eyes, ears, noses, dental appliances, osotmy products, or devices such as eyelashes or wigs.

4-20

     (5) "Prosthetics" means the science and practice of evaluation, measuring, designing,

4-21

fabricating, assembling, fitting, aligning, adjusting or servicing, as well as providing the initial

4-22

training necessary to accomplish the fitting of, a prosthesis through the replacement of external

4-23

parts of a human body lost due to amputation or congenital deformities or absences. The practice

4-24

of prosthetics also includes the generation of an image, form, or mold that replicates the patient's

4-25

body or body segment and that requires rectification of dimensions, contours and volumes for use

4-26

in the design and fabrication of a socket to accept a residual anatomic limb to, in turn, create an

4-27

artificial appendage that is designed either to support body weight or to improve or restore

4-28

function or cosmesis, or both. Involved in the practice of prosthetics is observational gait analysis

4-29

and clinical assessment of the requirements necessary to refine and mechanically fix the relative

4-30

position of various parts of the prosthesis to maximize function, stability, and safety of the

4-31

patient. The practice of prosthetics includes providing and continuing patient care in order to

4-32

assess the prosthetic device's effect on the patient's tissues and to assure proper fit and function of

4-33

the prosthetic device by periodic evaluation.

4-34

     (6) "Private insurance company" means any insurance company, or management

5-1

company hired by an insurance company, who is any of the following:

5-2

     (i) based in the state of Rhode Island; or

5-3

     (ii) provides coverage for citizens for the state of Rhode Island; or

5-4

      (iii) allows subscribing patients to seek prosthetic or orthotic services in the state of

5-5

Rhode Island.

5-6

     (b) Every individual or group health insurance contract, plan or policy delivered, issued

5-7

for delivery or renewed in this state on or after January 1, 2006, which provides medical coverage

5-8

that includes coverage for physician services in a physician's office and every policy, which

5-9

provides major medical or similar comprehensive type coverage shall provide coverage for

5-10

benefits for orthotic and prosthetic devices that equal those benefits provided for under federal

5-11

laws for health insurance for the aged and disabled pursuant to 42 U.S.C. sections 1395K, 13951

5-12

and 1395M and 42 CFR 414.202, 414.210, 414.228, and 410.100 as applicable to this section.

5-13

     (c) A health insurance contract, plan or policy may require prior authorization for orthotic

5-14

and prosthetic devices in the same manner that prior authorization is required for any other

5-15

covered benefit.

5-16

     (d) Covered benefits for orthotic or prosthetic devices shall be limited to the most

5-17

appropriate model that adequately meets the medical needs of the patient as determined by the

5-18

insured's treating physician.

5-19

     (e) The repair and replacement of orthotic or prosthetic devices also shall be covered

5-20

subject to co-payments and deductibles, unless necessitated by misuse or loss.

5-21

     (f) An insurer may require, if coverage is provided through a managed care plan, that

5-22

benefits mandated pursuant to this section be covered benefits only if the orthotic or prosthetic

5-23

devices are provided by a vendor and orthotic or prosthetic services are rendered by a provider

5-24

who is licensed by the state of Rhode Island to provide orthotics and prosthetics.

5-25

     SECTION 3. Chapter 27-20 of the General Laws entitled "Nonprofit Medical Service

5-26

Corporations" is hereby amended by adding thereto the following section:

5-27

     27-20-50. Reimbursement for orthotics and prosthetic services. -- (a) As used in this

5-28

section:

5-29

     (1) "Federal reimbursement rates" means the current listed fee schedule from the Centers

5-30

for Medicare and Medicaid Services, listing the current Healthcare Common Procedure Coding

5-31

system (HCPCS) and the corresponding reimbursement rates.

5-32

     (2) "Orthosis" means a custom fabricated brace or support that is designed based on

5-33

medical necessity. Orthosis does not include prefabricated or direct-formed orthotic devices, as

5-34

defined in this section, or any of the following assistive technology devices: commercially

6-1

available knee orthoses used following injury or surgery; spastic muscle-tone inhibiting orthoses;

6-2

upper extremity adaptive equipment; finger splints; hand splints; wrist gauntlets; face masks used

6-3

following burns; wheelchair seating that is an integral part of the wheelchair and not worn by the

6-4

patient independent of the wheelchair; fabric or elastic supports; corsets; low-temperature formed

6-5

plastic splints; trusses; elastic hose; canes; crutches; cervical collars; dental appliances; and other

6-6

similar devices as determined by the director of the department of health, such as those

6-7

commonly carried in stock by a pharmacy, department store, corset shop, or surgical supply

6-8

facility.

6-9

     (3) "Orthotics" means the science and practice of evaluating measuring, designing,

6-10

fabricating, assembling, fitting, adjusting or servicing, as well as providing the initial training

6-11

necessary to accomplish the fitting of, an orthosis for the support, correction, or alleviation of

6-12

neuromuscular or musculoskeletal dysfunction, disease, injury or deformity. The practice of

6-13

orthotics encompasses evaluation, treatment, and consultation; with basic observational gait and

6-14

postural analysis, orthotists assess and design orthoses to maximize function and provide not only

6-15

the support but the alignment necessary to either prevent or correct a deformity or to improve the

6-16

safety and efficiency of mobility or locomotion or both. Orthotic practice includes providing

6-17

continuing patient care in order to assess its effect on the patient's tissues and to assure proper fit

6-18

and function of the orthotic device by periodic evaluation.

6-19

     (4) "Prosthesis" means an artificial limb that is alignable or, in lower-extremity

6-20

applications capable of weight bearing. Prosthesis means an artificial medical device that is not

6-21

surgically implanted and that is used to replace a missing limb, appendage, or other external

6-22

human body part including an artificial limb, hand, or foot. The term does not include artificial

6-23

eyes, ears, noses, dental appliances, osotmy products, or devices such as eyelashes or wigs.

6-24

     (5) "Prosthetics" means the science and practice of evaluation, measuring, designing,

6-25

fabricating, assembling, fitting, aligning, adjusting or servicing, as well as providing the initial

6-26

training necessary to accomplish the fitting of, a prosthesis through the replacement of external

6-27

parts of a human body lost due to amputation or congenital deformities or absences. The practice

6-28

of prosthetics also includes the generation of an image, form, or mold that replicates the patient's

6-29

body or body segment and that requires rectification of dimensions, contours and volumes for use

6-30

in the design and fabrication of a socket to accept a residual anatomic limb to, in turn, create an

6-31

artificial appendage that is designed either to support body weight or to improve or restore

6-32

function or cosmesis, or both. Involved in the practice of prosthetics is observational gait analysis

6-33

and clinical assessment of the requirements necessary to refine and mechanically fix the relative

6-34

position of various parts of the prosthesis to maximize function, stability, and safety of the

7-1

patient. The practice of prosthetics includes providing and continuing patient care in order to

7-2

assess the prosthetic device's effect on the patient's tissues and to assure proper fit and function of

7-3

the prosthetic device by periodic evaluation.

7-4

     (6) "Private insurance company" means any insurance company, or management

7-5

company hired by an insurance company, who is any of the following:

7-6

     (i) based in the state of Rhode Island; or

7-7

     (ii) provides coverage for citizens for the state of Rhode Island; or

7-8

      (iii) allows subscribing patients to seek prosthetic or orthotic services in the state of

7-9

Rhode Island.

7-10

     (b) Every individual or group health insurance contract, plan or policy delivered, issued

7-11

for delivery or renewed in this state on or after January 1, 2006, which provides medical coverage

7-12

that includes coverage for physician services in a physician's office and every policy, which

7-13

provides major medical or similar comprehensive type coverage shall provide coverage for

7-14

benefits for orthotic and prosthetic devices that equal those benefits provided for under federal

7-15

laws for health insurance for the aged and disabled pursuant to 42 U.S.C. sections 1395K, 13951

7-16

and 1395M and 42 CFR 414.202, 414.210, 414.228, and 410.100 as applicable to this section.

7-17

     (c) A health insurance contract, plan or policy may require prior authorization for orthotic

7-18

and prosthetic devices in the same manner that prior authorization is required for any other

7-19

covered benefit.

7-20

     (d) Covered benefits for orthotic or prosthetic devices shall be limited to the most

7-21

appropriate model that adequately meets the medical needs of the patient as determined by the

7-22

insured's treating physician.

7-23

     (e) The repair and replacement of orthotic or prosthetic devices also shall be covered

7-24

subject to co-payments and deductibles, unless necessitated by misuse or loss.

7-25

     (f) An insurer may require, if coverage is provided through a managed care plan, that

7-26

benefits mandated pursuant to this section be covered benefits only if the orthotic or prosthetic

7-27

devices are provided by a vendor and orthotic or prosthetic services are rendered by a provider

7-28

who is licensed by the state of Rhode Island to provide orthotics and prosthetics.

7-29

     SECTION 4. Chapter 27-40 of the General Laws entitled "Insurance Premium Finance

7-30

Agreements" is hereby amended by adding thereto the following section:

7-31

     27-40-69. Reimbursement for orthotic and prosthetic services. -- (a) As used in this

7-32

section:

7-33

     (1) "Federal reimbursement rates" means the current listed fee schedule from the Centers

7-34

for Medicare and Medicaid Services, listing the current Healthcare Common Procedure Coding

8-1

system (HCPCS) and the corresponding reimbursement rates.

8-2

     (2) "Orthosis" means a custom fabricated brace or support that is designed based on

8-3

medical necessity. Orthosis does not include prefabricated or direct-formed orthotic devices, as

8-4

defined in this section, or any of the following assistive technology devices: commercially

8-5

available knee orthoses used following injury or surgery; spastic muscle-tone inhibiting orthoses;

8-6

upper extremity adaptive equipment; finger splints; hand splints; wrist gauntlets; face masks used

8-7

following burns; wheelchair seating that is an integral part of the wheelchair and not worn by the

8-8

patient independent of the wheelchair; fabric or elastic supports; corsets; low-temperature formed

8-9

plastic splints; trusses; elastic hose; canes; crutches; cervical collars; dental appliances; and other

8-10

similar devices as determined by the director of the department of health, such as those

8-11

commonly carried in stock by a pharmacy, department store, corset shop, or surgical supply

8-12

facility.

8-13

     (3) "Orthotics" means the science and practice of evaluating measuring, designing,

8-14

fabricating, assembling, fitting, adjusting or servicing, as well as providing the initial training

8-15

necessary to accomplish the fitting of, an orthosis for the support, correction, or alleviation of

8-16

neuromuscular or musculoskeletal dysfunction, disease, injury or deformity. The practice of

8-17

orthotics encompasses evaluation, treatment, and consultation; with basic observational gait and

8-18

postural analysis, orthotists assess and design orthoses to maximize function and provide not only

8-19

the support but the alignment necessary to either prevent or correct a deformity or to improve the

8-20

safety and efficiency of mobility or locomotion or both. Orthotic practice includes providing

8-21

continuing patient care in order to assess its effect on the patient's tissues and to assure proper fit

8-22

and function of the orthotic device by periodic evaluation.

8-23

     (4) "Prosthesis" means an artificial limb that is alignable or, in lower-extremity

8-24

applications capable of weight bearing. Prosthesis means an artificial medical device that is not

8-25

surgically implanted and that is used to replace a missing limb, appendage, or other external

8-26

human body part including an artificial limb, hand, or foot. The term does not include artificial

8-27

eyes, ears, noses, dental appliances, osotmy products, or devices such as eyelashes or wigs.

8-28

     (5) "Prosthetics" means the science and practice of evaluation, measuring, designing,

8-29

fabricating, assembling, fitting, aligning, adjusting or servicing, as well as providing the initial

8-30

training necessary to accomplish the fitting of, a prosthesis through the replacement of external

8-31

parts of a human body lost due to amputation or congenital deformities or absences. The practice

8-32

of prosthetics also includes the generation of an image, form, or mold that replicates the patient's

8-33

body or body segment and that requires rectification of dimensions, contours and volumes for use

8-34

in the design and fabrication of a socket to accept a residual anatomic limb to, in turn, create an

9-1

artificial appendage that is designed either to support body weight or to improve or restore

9-2

function or cosmesis, or both. Involved in the practice of prosthetics is observational gait analysis

9-3

and clinical assessment of the requirements necessary to refine and mechanically fix the relative

9-4

position of various parts of the prosthesis to maximize function, stability, and safety of the

9-5

patient. The practice of prosthetics includes providing and continuing patient care in order to

9-6

assess the prosthetic device's effect on the patient's tissues and to assure proper fit and function of

9-7

the prosthetic device by periodic evaluation.

9-8

     (6) "Private insurance company" means any insurance company, or management

9-9

company hired by an insurance company, who is any of the following:

9-10

     (i) based in the state of Rhode Island; or

9-11

     (ii) provides coverage for citizens for the state of Rhode Island; or

9-12

      (iii) allows subscribing patients to seek prosthetic or orthotic services in the state of

9-13

Rhode Island.

9-14

     (b) Every individual or group health insurance contract, plan or policy delivered, issued

9-15

for delivery or renewed in this state on or after January 1, 2006, which provides medical coverage

9-16

that includes coverage for physician services in a physician's office and every policy, which

9-17

provides major medical or similar comprehensive type coverage shall provide coverage for

9-18

benefits for orthotic and prosthetic devices that equal those benefits provided for under federal

9-19

laws for health insurance for the aged and disabled pursuant to 42 U.S.C. sections 1395K, 13951

9-20

and 1395M and 42 CFR 414.202, 414.210, 414.228, and 410.100 as applicable to this section.

9-21

     (c) A health insurance contract, plan or policy may require prior authorization for orthotic

9-22

and prosthetic devices in the same manner that prior authorization is required for any other

9-23

covered benefit.

9-24

     (d) Covered benefits for orthotic or prosthetic devices shall be limited to the most

9-25

appropriate model that adequately meets the medical needs of the patient as determined by the

9-26

insured's treating physician.

9-27

     (e) The repair and replacement of orthotic or prosthetic devices also shall be covered

9-28

subject to co-payments and deductibles, unless necessitated by misuse or loss.

9-29

     (f) An insurer may require, if coverage is provided through a managed care plan, that

9-30

benefits mandated pursuant to this section be covered benefits only if the orthotic or prosthetic

9-31

devices are provided by a vendor and orthotic or prosthetic services are rendered by a provider

9-32

who is licensed by the state of Rhode Island to provide orthotics and prosthetics.

10-1

     SECTION 5. This act shall take effect upon passage.

     

=======

LC00756

========

EXPLANATION

BY THE LEGISLATIVE COUNCIL

OF

A N A C T

RELATING TO HEALTH INSURANCE COVERAGE -- ORTHOTIC AND PROSTHETIC

SERVICES

***

11-1

     This act would require that health insurance policies provide orthotic and prosthetic

11-2

devices at a reimbursement rate equal to those provided for under federal laws for aged and

11-3

disabled persons.

11-4

     This act would take effect upon passage.

     

=======

LC00756

=======

S2176