BILL REQ. #:  H-1122.1 

Read first time 01/27/11.   Referred to Committee on Health Care & Wellness.

     AN ACT Relating to insurance coverage of prosthetics and orthotics; and adding a new section to chapter 48.43 RCW.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:

NEW SECTION.  Sec. 1   A new section is added to chapter 48.43 RCW to read as follows:
     (1) Each individual and group health plan that is issued or renewed on or after January 1, 2012, that provides coverage for hospital or medical expenses shall provide coverage for benefits for prosthetics and orthotics that are at least equivalent to the coverage provided by the federal medicare program, and no less favorable than the terms and conditions for the medical and surgical benefits in the policy.
     (a) "Orthotic device" means a rigid or semirigid device supporting a weak or deformed leg, foot, arm, hand, back, or neck, or restricting or eliminating motion in a diseased or injured leg, foot, arm, hand, back, or neck.
     (b) "Prosthetic device" means an artificial limb device or appliance designed to replace in whole or in part an arm or a leg.
     (2) Coverage required under this section includes all services and supplies determined medically necessary by the treating physician to restore functionality to optimal levels. The coverage includes all services and supplies necessary for the effective use of a prosthetic or orthotic 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. The coverage includes all materials and components necessary to use the device.
     (3) The reimbursement rate for prosthetic and orthotic devices must be at least equivalent to that currently provided by the federal medicare program and no more restrictive than other benefits in the policy and must be comparable to coverage of restorative internal devices without arbitrary caps or lifetime restrictions.
     (4) The coverage must include any repair or replacement of a prosthetic or orthotic device that is determined medically necessary to restore or maintain the ability to complete activities of daily living or essential job-related activities and that is not solely for comfort or convenience.
     (5) Prosthetic and orthotic benefits may not be subject to separate financial requirements or limitations. A health plan may impose copayment or coinsurance amounts on prosthetics, however financial requirements may be no more restrictive than the financial requirements applicable to the medical and surgical benefits, including those for internal devices.
     (6) A health plan may limit the benefits or alter the financial requirements for out-of-network coverage of prosthetic and orthotic devices. However, the restrictions and requirements applicable to the benefits may be no more restrictive than the financial requirements applicable to the out-of-network coverage for the medical and surgical benefits.
     (7) A health plan may not impose any annual or lifetime dollar maximum on coverage for prosthetics other than an annual or lifetime dollar maximum that applies in the aggregate to all terms and services covered under the policy.
     (8) If coverage is provided through a managed care plan, the insured must have access to medically necessary clinical care and to prosthetic and orthotic devices and technology from not less than two distinct prosthetic and orthotic providers in the plan's provider network.