HF 3339

1st Engrossment - 93rd Legislature (2023 - 2024) Posted on 03/11/2024 04:37pm

A bill for an act
relating to insurance; requiring coverage for orthotic and prosthetic devices;
authorizing rulemaking; amending Minnesota Statutes 2022, section 256B.0625,
subdivision 12, by adding a subdivision; proposing coding for new law in Minnesota
Statutes, chapters 62Q; 256B.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MINNESOTA:

Section 1.

new text begin [62Q.665] COVERAGE FOR ORTHOTIC AND PROSTHETIC DEVICES.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin (a) For the purposes of this section, the following terms have
the meanings given.
new text end

new text begin (b) "Accredited facility" means any entity that is accredited to provide comprehensive
orthotic or prosthetic devices or services by a Centers for Medicare and Medicaid Services
approved accrediting agency.
new text end

new text begin (c) "Orthosis" means:
new text end

new text begin (1) an external medical device that is:
new text end

new text begin (i) custom-fabricated or custom-fitted to a specific patient based on the patient's unique
physical condition;
new text end

new text begin (ii) applied to a part of the body to correct a deformity, provide support and protection,
restrict motion, improve function, or relieve symptoms of a disease, syndrome, injury, or
postoperative condition; and
new text end

new text begin (iii) deemed medically necessary by a prescribing physician or licensed health care
provider who has authority in Minnesota to prescribe orthotic and prosthetic devices, supplies,
and services; and
new text end

new text begin (2) any provision, repair, or replacement of a device that is furnished or performed by:
new text end

new text begin (i) an accredited facility in comprehensive orthotic services; or
new text end

new text begin (ii) a health care provider licensed in Minnesota and operating within the provider's
scope of practice which allows the provider to provide orthotic or prosthetic devices, supplies,
or services.
new text end

new text begin (d) "Orthotics" means:
new text end

new text begin (1) the science and practice of evaluating, measuring, designing, fabricating, assembling,
fitting, adjusting, or servicing and providing the initial training necessary to accomplish the
fitting of an orthotic device for the support, correction, or alleviation of a neuromuscular
or musculoskeletal dysfunction, disease, injury, or deformity;
new text end

new text begin (2) evaluation, treatment, and consultation related to an orthotic device;
new text end

new text begin (3) basic observation of gait and postural analysis;
new text end

new text begin (4) assessing and designing orthosis to maximize function and provide support and
alignment necessary to prevent or correct a deformity or to improve the safety and efficiency
of mobility and locomotion;
new text end

new text begin (5) continuing patient care to assess the effect of an orthotic device on the patient's
tissues; and
new text end

new text begin (6) proper fit and function of the orthotic device by periodic evaluation.
new text end

new text begin (e) "Prosthesis" means:
new text end

new text begin (1) an external medical device that is:
new text end

new text begin (i) used to replace or restore a missing limb, appendage, or other external human body
part; and
new text end

new text begin (ii) deemed medically necessary by a prescribing physician or licensed health care
provider who has authority in Minnesota to prescribe orthotic and prosthetic devices, supplies,
and services; and
new text end

new text begin (2) any provision, repair, or replacement of a device that is furnished or performed by:
new text end

new text begin (i) an accredited facility in comprehensive prosthetic services; or
new text end

new text begin (ii) a health care provider licensed in Minnesota and operating within the provider's
scope of practice which allows the provider to provide orthotic or prosthetic devices, supplies,
or services.
new text end

new text begin (f) "Prosthetics" means:
new text end

new text begin (1) the science and practice of evaluating, measuring, designing, fabricating, assembling,
fitting, aligning, adjusting, or servicing, as well as providing the initial training necessary
to accomplish the fitting of, a prosthesis through the replacement of external parts of a
human body lost due to amputation or congenital deformities or absences;
new text end

new text begin (2) the generation of an image, form, or mold that replicates the patient's body segment
and that requires rectification of dimensions, contours, and volumes for use in the design
and fabrication of a socket to accept a residual anatomic limb to, in turn, create an artificial
appendage that is designed either to support body weight or to improve or restore function
or anatomical appearance, or both;
new text end

new text begin (3) observational gait analysis and clinical assessment of the requirements necessary to
refine and mechanically fix the relative position of various parts of the prosthesis to maximize
function, stability, and safety of the patient;
new text end

new text begin (4) providing and continuing patient care in order to assess the prosthetic device's effect
on the patient's tissues; and
new text end

new text begin (5) assuring proper fit and function of the prosthetic device by periodic evaluation.
new text end

new text begin Subd. 2. new text end

new text begin Coverage. new text end

new text begin (a) A health plan must provide coverage for orthotic and prosthetic
devices, supplies, and services, including repair and replacement, at least equal to the
coverage provided under federal law for health insurance for the aged and disabled under
sections 1832, 1833, and 1834 of the Social Security Act, United States Code, title 42,
sections 1395k, 1395l, and 1395m, but only to the extent consistent with this section.
new text end

new text begin (b) A health plan must not subject orthotic and prosthetic benefits to separate financial
requirements that apply only with respect to those benefits. A health plan may impose
co-payment and coinsurance amounts on those benefits, except that any financial
requirements that apply to such benefits must not be more restrictive than the financial
requirements that apply to the health plan's medical and surgical benefits, including those
for internal restorative devices.
new text end

new text begin (c) A health plan may limit the benefits for, or alter the financial requirements for,
out-of-network coverage of prosthetic and orthotic devices, except that the restrictions and
requirements that apply to those benefits must not be more restrictive than the financial
requirements that apply to the out-of-network coverage for the health plan's medical and
surgical benefits.
new text end

new text begin (d) A health plan must cover orthoses and prostheses when furnished under an order by
a prescribing physician or licensed health care prescriber who has authority in Minnesota
to prescribe orthoses and prostheses, and that coverage for orthotic and prosthetic devices,
supplies, accessories, and services must include those devices or device systems, supplies,
accessories, and services that are customized to the covered individual's needs.
new text end

new text begin (e) A health plan must cover orthoses and prostheses determined by the enrollee's provider
to be the most appropriate model that meets the medical needs of the enrollee for purposes
of performing physical activities, as applicable, including but not limited to running, biking,
and swimming, and maximizing the enrollee's limb function.
new text end

new text begin (f) A health plan must cover orthoses and prostheses for showering or bathing.
new text end

new text begin Subd. 3. new text end

new text begin Prior authorization. new text end

new text begin A health plan may require prior authorization for orthotic
and prosthetic devices, supplies, and services in the same manner and to the same extent as
prior authorization is required for any other covered benefit.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective August 1, 2023, and applies to all health
plans offered, issued, or renewed on or after that date.
new text end

Sec. 2.

new text begin [62Q.666] MEDICAL NECESSITY AND NONDISCRIMINATION
STANDARDS FOR COVERAGE OF PROSTHETICS OR ORTHOTICS.
new text end

new text begin (a) When performing a utilization review for a request for coverage of prosthetic or
orthotic benefits, a health plan company shall apply the most recent version of evidence-based
treatment and fit criteria as recognized by relevant clinical specialists.
new text end

new text begin (b) A health plan company shall render utilization review determinations in a
nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative
benefits, including prosthetics or orthotics, solely on the basis of an enrollee's actual or
perceived disability.
new text end

new text begin (c) A health plan company shall not deny a prosthetic or orthotic benefit for an individual
with limb loss or absence that would otherwise be covered for a nondisabled person seeking
medical or surgical intervention to restore or maintain the ability to perform the same
physical activity.
new text end

new text begin (d) A health plan offered, issued, or renewed in Minnesota that offers coverage for
prosthetics and custom orthotic devices shall include language describing an enrollee's rights
pursuant to paragraphs (b) and (c) in its evidence of coverage and any benefit denial letters.
new text end

new text begin (e) A health plan that provides coverage for prosthetic or orthotic services shall ensure
access to medically necessary clinical care and to prosthetic and custom orthotic devices
and technology from not less than two distinct prosthetic and custom orthotic providers in
the plan's provider network located in Minnesota. In the event that medically necessary
covered orthotics and prosthetics are not available from an in-network provider, the health
plan company shall provide processes to refer a member to an out-of-network provider and
shall fully reimburse the out-of-network provider at a mutually agreed upon rate less member
cost sharing determined on an in-network basis.
new text end

new text begin (f) If coverage for prosthetic or custom orthotic devices is provided, payment shall be
made for the replacement of a prosthetic or custom orthotic device or for the replacement
of any part of the devices, without regard to continuous use or useful lifetime restrictions,
if an ordering health care provider determines that the provision of a replacement device,
or a replacement part of a device, is necessary because:
new text end

new text begin (1) of a change in the physiological condition of the patient;
new text end

new text begin (2) of an irreparable change in the condition of the device or in a part of the device; or
new text end

new text begin (3) the condition of the device, or the part of the device, requires repairs and the cost of
the repairs would be more than 60 percent of the cost of a replacement device or of the part
being replaced.
new text end

new text begin (g) Confirmation from a prescribing health care provider may be required if the prosthetic
or custom orthotic device or part being replaced is less than three years old.
new text end

Sec. 3.

Minnesota Statutes 2022, section 256B.0625, subdivision 12, is amended to read:

Subd. 12.

Eyeglasses deleted text begin , deleted text end new text begin and new text end dentures deleted text begin , and prosthetic and orthotic devices deleted text end .

deleted text begin (a) deleted text end Medical
assistance covers eyeglasses deleted text begin , deleted text end new text begin and new text end dentures deleted text begin , and prosthetic and orthotic devices deleted text end if prescribed
by a licensed practitioner.

deleted text begin (b) For purposes of prescribing prosthetic and orthotic devices, "licensed practitioner"
includes a physician, an advanced practice registered nurse, a physician assistant, or a
podiatrist.
deleted text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2025.
new text end

Sec. 4.

Minnesota Statutes 2022, section 256B.0625, is amended by adding a subdivision
to read:

new text begin Subd. 72. new text end

new text begin Orthotic and prosthetic devices. new text end

new text begin Medical assistance covers orthotic and
prosthetic devices, supplies, and services according to section 256B.066.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2025.
new text end

Sec. 5.

new text begin [256B.066] ORTHOTIC AND PROSTHETIC DEVICES, SUPPLIES, AND
SERVICES.
new text end

new text begin Subdivision 1. new text end

new text begin Definitions. new text end

new text begin All terms used in this section have the meanings given them
in section 62Q.665, subdivision 1.
new text end

new text begin Subd. 2. new text end

new text begin Coverage requirements. new text end

new text begin (a) Medical assistance covers orthotic and prosthetic
devices, supplies, and services:
new text end

new text begin (1) furnished under an order by a prescribing physician or licensed health care prescriber
who has authority in Minnesota to prescribe orthoses and prostheses. Coverage for orthotic
and prosthetic devices, supplies, accessories, and services under this clause includes those
devices or device systems, supplies, accessories, and services that are customized to the
enrollee's needs;
new text end

new text begin (2) determined by the enrollee's provider to be the most appropriate model that meets
the medical needs of the enrollee for purposes of performing physical activities, as applicable,
including but not limited to running, biking, and swimming, and maximizing the enrollee's
limb function; or
new text end

new text begin (3) for showering or bathing.
new text end

new text begin (b) The coverage set forth in paragraph (a) includes the repair and replacement of those
orthotic and prosthetic devices, supplies, and services described therein.
new text end

new text begin (c) Coverage of a prosthetic or orthotic benefit must not be denied for an individual with
limb loss or absence that would otherwise be covered for a nondisabled person seeking
medical or surgical intervention to restore or maintain the ability to perform the same
physical activity.
new text end

new text begin (d) If coverage for prosthetic or custom orthotic devices is provided, payment shall be
made for the replacement of a prosthetic or custom orthotic device or for the replacement
of any part of the devices, without regard to continuous use or useful lifetime restrictions,
if an ordering health care provider determines that the provision of a replacement device,
or a replacement part of a device, is necessary because:
new text end

new text begin (1) of a change in the physiological condition of the patient;
new text end

new text begin (2) of an irreparable change in the condition of the device or in a part of the device; or
new text end

new text begin (3) the condition of the device, or the part of the device, requires repairs and the cost of
the repairs would be more than 60 percent of the cost of a replacement device or of the part
being replaced.
new text end

new text begin Subd. 3. new text end

new text begin Restrictions on coverage. new text end

new text begin (a) Prior authorization may be required for orthotic
and prosthetic devices, supplies, and services.
new text end

new text begin (b) A utilization review for a request for coverage of prosthetic or orthotic benefits must
apply the most recent version of evidence-based treatment and fit criteria as recognized by
relevant clinical specialists.
new text end

new text begin (c) Utilization review determinations must be rendered in a nondiscriminatory manner
and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics
or orthotics, solely on the basis of an enrollee's actual or perceived disability.
new text end

new text begin (d) Evidence of coverage and any benefit denial letters must include language describing
an enrollee's rights pursuant to paragraphs (b) and (c).
new text end

new text begin (e) Confirmation from a prescribing health care provider may be required if the prosthetic
or custom orthotic device or part being replaced is less than three years old.
new text end

new text begin Subd. 4. new text end

new text begin Managed care plan access to care. new text end

new text begin (a) Managed care plans and county-based
purchasing plans subject to this section must ensure access to medically necessary clinical
care and to prosthetic and custom orthotic devices and technology from at least two distinct
prosthetic and custom orthotic providers in the plan's provider network located in Minnesota.
new text end

new text begin (b) In the event that medically necessary covered orthotics and prosthetics are not
available from an in-network provider, the plan must provide processes to refer an enrollee
to an out-of-network provider and must fully reimburse the out-of-network provider at a
mutually agreed upon rate less enrollee cost sharing determined on an in-network basis.
new text end

new text begin EFFECTIVE DATE. new text end

new text begin This section is effective January 1, 2025.
new text end