AN ACT EXPANDING HEALTH INSURANCE COVERAGE FOR OSTOMY SUPPLIES.

The bill increases, to $ 5,000 from $ 1,000, the annual coverage amount required in certain health insurance policies for medically necessary ostomy appliances and supplies, including collection devices, irrigation equipment and supplies, and skin barriers and protectors.

By law, the benefit requirement applies to individual and group health insurance policies delivered, issued, renewed, or continued in Connecticut that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services, including coverage under an HMO plan. The bill makes the requirement also apply to policies including such coverage that are amended.

Due to federal law (ERISA), state insurance benefit mandates do not apply to self-insured benefit plans.

By law, policies that cover ostomy, colostomy, ileostomy, or urostomy surgery must include the benefit. The law prohibits insurers from applying any payments for ostomy appliances and supplies toward any durable medical equipment benefit maximum. And such payments cannot be used to decrease policy benefits that exceed the required coverage amount.

An ostomy is a surgically formed artificial opening in the bowel or intestine. A colostomy is an artificial opening in the colon. An ileostomy is an artificial opening in the small intestine or ileum. An urostomy is an artificial opening in the tubes that run from the kidney to the bladder.

The law defines “medically necessary” as health care services that a physician, exercising prudent clinical judgment, would provide to a patient to prevent, evaluate, diagnose, or treat an illness, injury, disease, or its symptoms, and that are:

1. in accordance with generally accepted standards of medical practice;

2. clinically appropriate, in terms of type, frequency, extent, site, and duration and considered effective for the patient's illness, injury, or disease;

3. not primarily for the convenience of the patient, physician, or other health care provider; and

4. and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results.

“Generally accepted standards of medical practice” means standards that are (1) based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community or (2) otherwise consistent with the standards set forth in policy issues involving clinical judgment.

Yea

Nay

(02/19/2009)