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SF 1075

as introduced - 88th Legislature (2013 - 2014) Posted on 03/06/2013 08:55am

KEY: stricken = removed, old language. underscored = added, new language.

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Current Version - as introduced

A bill for an act
relating to insurance; requiring coverage for orthotic and prosthetic devices;
proposing coding for new law in Minnesota Statutes, chapter 62Q.

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

Section 1.

[62Q.665] COVERAGE FOR ORTHOTIC AND PROSTHETIC
DEVICES.

Subdivision 1.

Definitions.

The following definitions have the meanings given for
purposes of this section.

(a) "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.

(b) "Orthosis" means:

(1) an external medical device that is custom-fabricated or custom-fitted to a specific
patient based on the patient's unique physical condition and is 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 is
deemed medically necessary by a prescribing physician or licensed health care prescriber
who has authority in this state to prescribe orthotic and prosthetic devices, supplies, and
services; and

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

(i) an accredited facility in comprehensive orthotic services; or

(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.

(c) "Orthotics" means:

(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;

(2) evaluation, treatment, and consultation;

(3) basic observation of gait and postural analysis;

(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;

(5) continuing patient care to assess the effect on the patient's tissues; and

(6) proper fit and function of the orthotic device by periodic evaluation.

(d) "Prosthesis" means an external medical device that is used to replace or restore
a missing limb, appendage, or other external human body part and is deemed medically
necessary by a prescribing physician or licensed health care prescriber who has authority
in this state to prescribe orthotic and prosthetic devices, supplies, and services. Prosthesis
includes any provision, repair, or replacement of a device that is furnished or performed by:

(1) an accredited facility in comprehensive prosthetic services; or

(2) 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.

(e) "Prosthetics" means 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. The practice of prosthetics also includes 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. Involved in the practice of prosthetics is 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. The practice of prosthetics includes providing and continuing patient care in order
to assess the prosthetic device's effect on the patient's tissues and to assure proper fit and
function of the prosthetic device by periodic evaluation.

Subd. 2.

Coverage.

(a) A health plan shall provide coverage for orthotic and
prosthetic devices, supplies, and services, including repair and replacement, to the extent
that coverage is 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.

(b) Orthotic and prosthetic device coverage under this section may be subject only
to the annual or lifetime dollar maximum that applies generally to all terms and services
covered under the plan.

(c) Orthotic and prosthetic benefits must not be subject 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; however, any financial
requirements that apply to such benefits may be no more restrictive than the financial
requirements that apply to the health plan's medical and surgical benefits, including those
for internal restorative devices.

(d) A health plan may limit the benefits for, or alter the financial requirements for,
out-of-network coverage of prosthetic and orthotic devices; however, the restrictions and
requirements that apply to those benefits may be no more restrictive than the financial
requirements that apply to the out-of-network coverage for the health plan's medical
and surgical benefits.

(e) Coverage for orthotic and prosthetic devices, supplies, and services must not be
subject to any limitations for preexisting conditions.

(f) Orthoses and prostheses must be covered when furnished under an order by a
prescribing physician or licensed health care prescriber who has authority in this state 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.

Subd. 3.

Prior authorization.

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.

EFFECTIVE DATE.

This section is effective August 1, 2013, and applies to all
health plans issued or renewed to provide coverage for Minnesota residents on or after
that date.

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