Be
it enacted by the People of the State of Maine as
follows:
Sec. 1.
24-A MRSA §4315 is enacted to
read:
§4315.
Coverage of prosthetic devices
1.
Definition.
As used in this section, "prosthetic
device" means an artificial device to
replace, in whole or in part, an arm or a leg.
2.
Required coverage.
A carrier shall provide coverage for
prosthetic devices in all health plans that, at a
minimum, equals the coverage and payment for
prosthetic devices provided under federal laws and
regulations for the aged and disabled pursuant to
42 United States Code, Sections 1395k, 1395l and
1395m and 42 Code of Federal Regulations, Sections
414.202, 414.210, 414.228 and 410.100.
Covered benefits must be provided for a
prosthetic device determined by the enrollee's
provider to be the most appropriate model that
adequately meets the medical needs of the
enrollee.
3.
Prior authorization.
A carrier may require prior authorization
for prosthetic devices in the same manner as prior
authorization is required for any other covered
benefit.
4.
Repair or replacement.
Coverage under this section must also be
provided for repair or replacement of a prosthetic
device if repair or replacement is determined
appropriate by the enrollee's provider.
5.
Coverage under managed care plan.
If coverage under this section is provided
through a managed care plan, a carrier may require
that prosthetic services be rendered by a provider
who contracts with the carrier and that a
prosthetic device be provided by a vendor
designated by the carrier.
Sec.
2. Application.
The requirements of this Act apply to all
policies, contracts and certificates executed,
delivered, issued for delivery, continued or
renewed in this State on or after January 1, 2004.
For purposes of this Act, all contracts are
deemed to be renewed no later than the next yearly
anniversary of the contract date.
SUMMARY
This bill requires carriers to provide
coverage for prosthetic devices in all health
plans, except those providing supplemental
coverage for a specific disease or other limited
benefits. Benefits for coverage of prosthetic
devices must be equal
to those benefits provided under federal Medicare
law. Currently, Medicare provides coverage for 80%
of the actual charge or the amount recognized as
the purchase price for the device, whichever is
less.
The requirements apply to all health plan
policies issued or renewed on or after January 1,
2004.
