FIRST REGULAR SESSION
95TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVES COOPER (Sponsor), TALBOY, CHAPPELLE-NADAL, SCHIEFFER, MEINERS, BURNETT, SCHAAF AND CASEY (Co-sponsors).
1564L.01I D. ADAM CRUMBLISS, Chief Clerk
AN ACT
To amend chapter 376, RSMo, by adding thereto one new section relating to health insurance coverage for prosthetic devices.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be known as section 376.1223, to read as follows:
376.1223. 1. Each health carrier or health benefit plan that offers or issues health benefit plans which are delivered, issued for delivery, continued, or renewed in this state on or after January 1, 2010, shall provide coverage for prosthetic devices that, at a minimum, equals the coverage provided under the federal Medicare program under 42 U.S.C. Sections 1395k, 1395l, and 1395m and 42 CFR 414.100, 414.202, 414.210, and 414.228. The coverage required under this section shall include all services and supplies medically necessary for the effective use of a prosthetic device, including formulating its design, fabrication, material and component selection, measurements, fittings, static and dynamic alignments, and instructing the patient in the use of the device.
2. For the purposes of this section, the following terms shall mean:
(1) "Health benefit plan", the same meaning as such term is defined in section 376.1350;
(2) "Health carrier", the same meaning as such term is defined in section 376.1350;
(3) "Prosthetic device", an artificial limb, device, or appliance designed to replace in whole or in part arms, legs, or eyes as set forth in 42 U.S.C. Section 1395x(s)(9).
3. A health carrier may require prior authorization for prosthetic devices in the same manner that prior authorization is required for any other covered benefit.
4. A health benefit plan may be subject to coinsurance or co-payments on prosthetic devices in an amount not to exceed the coinsurance or co-payment amounts imposed under Part B of the Medicare fee-for-service program. A health benefit plan shall reimburse for such prosthetic devices at no less than the fee schedule amount for such prosthetic devices under the federal Medicare reimbursement schedule.
5. Covered benefits under this section shall be limited to the most appropriate model that adequately meets the medical needs of the insured to perform activities of daily living and essential job-related activities, as determined by the insured's treating physician.
6. The coverage required under this section shall include any repair or replacement of a prosthetic device that is determined medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities.
7. The health benefit plan shall not impose any annual or lifetime dollar limits on coverage for prosthetic devices other than an annual or lifetime dollar limit that applies in the aggregate to all terms and conditions covered under the plan.
8. The provisions of this section shall not apply to a supplemental insurance policy, including a life care contract, accident-only policy, specified disease policy, hospital policy providing a fixed daily benefit only, Medicare supplement policy, long-term care policy, short-term major medical policies of six months' or less duration, or any other supplemental policy as determined by the director of the department of insurance.
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