§ 15-844

(a) (1) In this section, “prosthesis” means an artificial device to replace, in whole or in part, a leg, an arm, or an eye.

(2) “Prosthesis” includes a custom–designed, –fabricated, –fitted, or –modified device to treat partial or total limb loss for purposes of restoring physiological function.

(b) This section applies to:

(1) insurers and nonprofit health service plans that provide hospital, medical, or surgical benefits to individuals or groups on an expense–incurred basis under health insurance policies or contracts that are issued or delivered in the State; and

(2) health maintenance organizations that provide hospital, medical, or surgical benefits to individuals or groups under contracts that are issued or delivered in the State.

(c) An entity subject to this section shall provide once annually coverage for:

(1) prostheses;

(2) components of prostheses;

(3) repairs to prostheses; and

(4) subject to subsection (d) of this section, replacements of prostheses or prosthesis components.

(d) (1) An entity subject to this section shall provide coverage for replacements of prostheses if an ordering health care provider determines that the provision of a replacement prosthesis or a component of the prosthesis is necessary:

(i) because of a change in the physiological condition of the patient;

(ii) unless necessitated by misuse, because of an irreparable change in the condition of the prosthesis or a component of the prosthesis; or

(iii) unless necessitated by misuse, because the condition of the prosthesis or the component of the prosthesis requires repairs and the cost of the repairs would be more than 60% of the cost of replacing the prosthesis or the component of the prosthesis.

(2) An entity subject to this section may require an ordering health care provider to confirm that the prosthesis or component of the prosthesis being replaced meets the requirements of paragraph (1) of this subsection if the prosthesis or component is less than 3 years old.

(e) The covered benefits under this section may not be subject to a higher copayment or coinsurance requirement than the copayment or coinsurance for other similar medical and surgical benefits covered under the policy or contract of the insured or enrollee.

(f) An entity subject to this section may not impose an annual or lifetime dollar maximum on coverage required under this section separate from any annual or lifetime dollar maximum that applies in the aggregate to all covered benefits under the policy or contract of the insured or enrollee.

(g) (1) An entity subject to this section may not establish requirements for medical necessity or appropriateness for the coverage required under this section that are more restrictive than the indications and limitations of coverage and medical necessity established under the Medicare Coverage Database.

(2) The covered benefits under this section include prostheses determined by a treating health care provider to be medically necessary for:

(i) completing activities of daily living;

(ii) essential job–related activities; or

(iii) performing physical activities, including running, biking, swimming, strength training, and other activities to maximize the whole–body health and lower or upper limb function of the insured or enrollee.

(h) An entity subject to this section that uses a provider panel for a policy or contract described in subsection (b) of this section and the provision of covered benefits under this section shall comply with § 15–112(b)(3) of this title.