§ 27-19-58. Reimbursement for orthotics and prosthetic services.
(a) As used in this section:
(1) "Federal reimbursement rates� means the current listed fee schedule from the Centers
for Medicare & Medicaid Services, listing the current Healthcare Common Procedure
Coding system (HCPCS) and the corresponding reimbursement rates.
(2) "Orthosis� means a custom fabricated brace or support that is designed based on medical
necessity. Orthosis does not include prefabricated or direct-formed orthotic devices,
as defined in this section, or any of the following assistive technology devices:
commercially available knee orthoses used following injury or surgery; spastic muscle-tone
inhibiting orthoses; upper extremity adaptive equipment; finger splints; hand splints;
wrist gauntlets; face masks used following burns; wheelchair seating that is an integral
part of the wheelchair and not worn by the patient independent of the wheelchair;
fabric or elastic supports; corsets; low-temperature formed plastic splints; trusses;
elastic hose; canes; crutches; cervical collars; dental appliances; and other similar
devices as determined by the director of the department of health, such as those commonly
carried in stock by a pharmacy, department store, corset shop, or surgical supply
facility.
(3) "Orthotics� means the science and practice of evaluating, measuring, designing, fabricating,
assembling, fitting, adjusting, or servicing, as well as providing the initial training
necessary to accomplish the fitting of, an orthosis for the support, correction, or
alleviation of neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.
The practice of orthotics encompasses evaluation, treatment, and consultation; with
basic observational gait and postural analysis, orthotists assess and design orthoses
to maximize function and provide not only the support but the alignment necessary
to either prevent or correct a deformity or to improve the safety and efficiency of
mobility or locomotion or both. Orthotic practice includes providing continuing patient
care in order to assess its effect on the patient's tissues and to ensure proper fit
and function of the orthotic device by periodic evaluation.
(4) "Private insurance company� means any insurance company, or management company hired
by an insurance company, that is any of the following:
(i) Based in the state of Rhode Island; or
(ii) Provides coverage for citizens for the state of Rhode Island; or
(iii) Allows subscribing patients to seek prosthetic or orthotic services in the state of
Rhode Island.
(5) "Prosthesis� means an artificial limb that is alignable or, in lower-extremity applications
capable of weight bearing. Prosthesis means an artificial medical device that is not
surgically implanted and that is used to replace a missing limb, appendage, or other
external human body part including an artificial limb, hand, or foot. The term does
not include artificial eyes, ears, noses, dental appliances, osotmy products, or devices
such as eyelashes or wigs.
(6) "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 or 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 cosmesis, 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 ensure proper fit and function of the prosthetic
device by periodic evaluation.
(b) Every individual or group health insurance contract, plan, or policy delivered, issued
for delivery, or renewed in this state on or after January 1, 2006, that provides
medical coverage that includes coverage for physician services in a physician's office
and every policy that provides major medical or similar comprehensive type coverage
shall provide coverage for benefits for orthotic and prosthetic devices that equal
those benefits provided for under federal laws for health insurance for the aged and
disabled pursuant to 42 U.S.C. §§ 1395k, 1395l, and 1395m and 42 C.F.R. §§â€‰ 414.202, 414.210, 414.228, and 410.100 as applicable to this section.
(c) A health insurance contract, plan, or policy may require prior authorization for orthotic
and prosthetic devices in the same manner that prior authorization is required for
any other covered benefit.
(d) Covered benefits for orthotic or prosthetic devices shall be limited to the most appropriate
model that adequately meets the medical needs of the patient as determined by the
insured's treating physician.
(e) The repair and replacement of orthotic or prosthetic devices also shall be covered
subject to copayments and deductibles, unless necessitated by misuse or loss.
(f) An insurer may require, if coverage is provided through a managed care plan, that
benefits mandated pursuant to this section be covered benefits only if the orthotic
or prosthetic devices are provided by a vendor and orthotic or prosthetic services
are rendered by a provider who is licensed by the state of Rhode Island to provide
orthotics and prosthetics.