§ 5-10-8-14 — Coverage for prosthetic devices

(a) As used in this section, "covered
individual" means an individual who is entitled to coverage under a
state employee health plan.
(b) As used in this section, "orthotic device" means a medically
necessary custom fabricated brace or support that is designed as a
component of a prosthetic device.
(c) As used in this section, "prosthetic device" means an artificial
leg or arm.
(d) As used in this section, "state employee health plan" means a:
(1) self-insurance program established under section 7(b) of this
chapter; or
(2) contract with a prepaid health care delivery plan that is
entered into or renewed under section 7(c) of this chapter;
to provide group health coverage. The term does not include a dental
or vision plan.
(e) A state employee health plan must provide coverage for orthotic
devices and prosthetic devices, including repairs or replacements, that:
(1) are provided or performed by a person that is:
(A) accredited as required under 42 U.S.C. 1395m(a)(20); or
(B) a qualified practitioner (as defined in 42 U.S.C.
1395m(h)(1)(F)(iii));
(2) are determined by the covered individual's physician to be
medically necessary to restore or maintain the covered
individual's ability to perform activities of daily living or essential
job related activities; and
(3) are not solely for comfort or convenience.
(f) The:
(1) coverage required under subsection (e) must be equal to the
coverage that is provided for the same device, repair, or
replacement under the federal Medicare program (42 U.S.C. 1395
et seq.); and
(2) reimbursement under the coverage required under subsection
(e) must be equal to the reimbursement that is provided for the
same device, repair, or replacement under the federal Medicare
reimbursement schedule, unless a different reimbursement rate is
negotiated.
This subsection does not require a deductible under a state employee
health plan to be equal to a deductible under the federal Medicare
program.
(g) Except as provided in subsections (h) and (i), the coverage
required under subsection (e):
(1) may be subject to; and
(2) may not be more restrictive than;
the provisions that apply to other benefits under the state employee
health plan.
(h) The coverage required under subsection (e) may be subject to
utilization review, including periodic review, of the continued medical
necessity of the benefit.
(i) Any lifetime maximum coverage limitation that applies to
prosthetic devices and orthotic devices:
(1) must not be included in; and
(2) must be equal to;
the lifetime maximum coverage limitation that applies to all other items
and services generally under the state employee health plan.
(j) For purposes of this subsection, "items and services" does not
include preventive services for which coverage is provided under a
high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26
U.S.C. 223(c)(2)). The coverage required under subsection (e) may not
be subject to a deductible, copayment, or coinsurance provision that is
less favorable to a covered individual than the deductible, copayment,
or coinsurance provisions that apply to other items and services
generally under the state employee health plan.

Legislative History

As added by P.L.109-2008, SEC.1.