AN ACT CONCERNING PROSTHETIC PARITY.

This bill requires a health insurance policy to cover prosthetic devices, and repairs and replacements to them, subject to specified conditions. It defines a “prosthetic device” as an artificial device to replace all or part of an arm or leg. It excludes a device that (1) contains a microprocessor or (2) is designed exclusively for athletic purposes.

Under the bill, the coverage must be at least equivalent to the coverage Medicare provides for such devices, but may be limited to a prosthetic device that the person's health care provider determines is most appropriate to meet his or her medical needs. (Medicare covers 80% of the cost of prostheses, after a person pays his or her annual deductible. )

The bill prohibits a policy from considering a prosthetic device as durable medical equipment. (Thus, the amount covered cannot count toward a durable medical equipment maximum. )

The bill applies to a policy, among others (see below), that a government entity issues covering Medicaid, HUSKY Plan, Charter Oak Health Plan, or state-administered assistance recipients by including these plans in the definition of “health insurance policy. ” (It is unclear how this requirement will be implemented or enforced, as these plans are not under the Insurance Department's jurisdiction. )

The bill requires a policy to cover repairs to or replacements of prosthetic devices that the person's heath care provider determines are medically necessary. It excludes coverage of repairs or replacements needed because of misuse or loss of the device.

The bill permits a person who is denied coverage for a prosthetic device, or device repair or replacement, to file an external appeal with the insurance commissioner in accordance with law.

The bill prohibits a policy from imposing a coinsurance, copayment, deductible, or other out-of-pocket expense for a prosthetic device that is more restrictive than that imposed on most other policy benefits. It specifies that this prohibition does not apply to a high-deductible health plan designed to be compatible with federally qualified health savings accounts.

The bill permits a policy to require prior authorization for prosthetic devices, but only in the same manner and to the same extent as prior authorization is required for other policy benefits.

The bill applies to individual and group health insurance policies that cover (1) basic hospital expenses; (2) basic medical-surgical expenses; (3) major medical expenses; and (4) hospital or medical services that are delivered, issued, renewed, amended, or continued in Connecticut by an:

1. insurer;

2. health care center (i. e. , HMO);

3. hospital or medical service corporation;

4. fraternal benefit society; or

5. government entity covering Medicaid, HUSKY Plan, Charter Oak Health Plan, or state-administered assistance recipients.

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

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. 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.

The law allows a person, or provider on his behalf, who has exhausted a health insurer's, managed care organization's (MCO), or utilization review (UR) company's internal appeal process to appeal to the insurance commissioner any claim denial based on medical necessity or decision not to certify an admission, service, procedure, or extension of stay.

The person or provider must submit the “external appeal” within 60 days of receiving a final determination from the insurer, MCO, or UR company to the commissioner on forms he prescribes. The appeal must include a general release for the person's medical records and a $ 25 processing fee, which the commissioner can waive for an indigent person. The company against who the appeal is filed must also pay a $ 25 fee. The commissioner assigns the appeal to an independent entity for review and a binding decision. The commissioner refunds (1) the company's fee if, after an initial review, the appeal is not accepted for a full review or (2) the prevailing party's fee after completing a full review.

Yea

Nay

(03/03/2009)