This section adds a new section to an existing chapter 48.43. Here is the modified chapter for context.
Health plans issued or renewed on or after January 1, 2022, must provide coverage for benefits for prosthetics and orthotics that are at least equivalent to the coverage provided by the federal medicare program, and no less favorable than the terms and conditions for the medical and surgical benefits in the policy.
Coverage required under this section includes all services and supplies determined medically necessary by the treating provider acting within the scope of his or her license, including services and supplies necessary for the effective use of a prosthetic or orthotic device, and materials and components necessary to use the device.
The reimbursement rate for prosthetic and orthotic devices must be at least equivalent to the medicare rate for the same or similar covered device.
Coverage required under this section must include any repair or replacement of a prosthetic or orthotic device that is determined medically necessary by the treating provider to restore or maintain the ability to complete activities of daily living or essential job-related activities and that is not solely for comfort or convenience.
If the health plan imposes any deductible, prosthetic and orthotic benefits must be included with medical and surgical services for the purpose of meeting the deductible requirement. A health plan may subject coverage of prosthetic and orthotic devices to copayment or coinsurance requirements.
A health plan may limit the benefits or alter the financial requirements for out-of-network coverage of prosthetic and orthotic devices. Restrictions and requirements applicable to the benefits may be no more restrictive than the financial requirements applicable to the out-of-network coverage for the medical and surgical benefits.
A health plan may not impose annual or lifetime dollar limits on coverage for prosthetic and orthotic devices.
The definitions in this subsection apply throughout this section unless the context clearly requires otherwise.
"Orthotic device" means a corrective or supportive device that prevents or corrects physical deformity or malfunction, or supports a weak or deformed portion of the body.
"Prosthetic device" means an artificial limb device to replace in whole or in part an arm or a leg.
The commissioner may adopt rules to implement this section.