§ 23-79-1502 — Craniofacial anomaly - Coverage for reconstructive surgery required

(a) (1) A health benefit plan that is offered, issued, provided, or renewed in this state shall include coverage and benefits for reconstructive surgery and related medical care for a person of any age who is diagnosed as having a craniofacial anomaly if the surgery and treatment are medically necessary to improve a functional impairment that results from the craniofacial anomaly as determined by a nationally approved cleft-craniofacial team, approved by the American Cleft Palate-Craniofacial Association in Chapel Hill, North Carolina. (2) A nationally approved cleft-craniofacial team for cleft-craniofacial conditions shall: (A) Evaluate a person with a craniofacial anomaly; and (B) Coordinate a treatment plan for each person. (3) After one (1) denial or any limitation of coverage that is based on the lack of medical necessity to improve a functional impairment, the case shall be referred for an external review under State Insurance Department Rule 76, the Arkansas External Review Regulation, if applicable, or under a similar procedure for external review established by a third-party administrator of a health benefit plan. (b) Medical care coverage required under this section includes coverage for reconstructive surgery, dental care, and vision care. (c) (1) The services included in the coverage described in subsection (b) of this section shall be authorized by a surgical member of a nationally approved cleft-craniofacial team of the American Cleft Palate-Craniofacial Association. (2) For healthcare services to be performed by a nationally approved cleft-craniofacial team, a request for written authorization or approval shall be reviewed by the administrator of the health benefit plan: (A) Within two (2) working days from the request by a nationally approved cleft-craniofacial surgical team member, for a nonurgent case; or (B) Within twenty-four (24) hours from the request by a nationally approved cleft-craniofacial surgical team member, for an urgent case. (3) (A) For healthcare services that are recommended by a surgical member of a nationally approved cleft-craniofacial team that are to be performed by a medical provider that is not on a nationally approved cleft-craniofacial team, a request for written authorization or approval shall be reviewed: (i) Within two (2) working days from the request by a nationally approved cleft-craniofacial surgical team member, for a nonurgent case; or (ii) Within twenty-four (24) hours from the request by a nationally approved cleft-craniofacial surgical team member, for an urgent case. (B) A medical provider that is not a craniofacial specialist shall communicate in a timely manner its proposed healthcare services to the nationally approved cleft-craniofacial surgical team member who initiated the recommendation described in subdivision (c)(3)(A) of this section. (d) A health benefit plan shall include coverage for the following, if medically necessary: (1) On an annual basis: (A) Scleral contact lenses, including coatings; (B) Office visits; (C) An ocular impression of each eye; and (D) Any additional tests or procedures that are medically necessary for a craniofacial patient; (2) (A) Every two (2) years, two (2) hearing aids and two (2) hearing aid molds for each ear. (B) As used in subdivision (d)(2)(A) of this section, "hearing aids" includes behind the ear, in the ear, wearable bone conductions, surgically implanted bone conduction services, and cochlear implants; and (3) Every four (4) years, a dehumidifier. (e) (1) A nationally approved cleft-craniofacial team that is located in other states may provide the healthcare services, treatment, evaluation, authorizations, and review as described in this section. (2) For healthcare services performed outside of this state under this section, the insured or enrollee shall not be penalized for out-of-network charges subject to the terms and conditions of the health benefit plan.

Legislative History

Amended by Act 2021, No. 955,§ 6, eff. 4/27/2021. Amended by Act 2021, No. 955,§ 5, eff. 4/27/2021. Amended by Act 2015, No. 373,§ 1, eff. 7/22/2015. Added by Act 2013, No. 1226,§ 1, eff. 8/16/2013.