Certain health coverage plans must cover prosthetic devices and prosthetic services, subject to stated limits and conditions.
§1049. Requirement for coverage of prosthetic devices and prosthetic services A. Notwithstanding the provisions of R.S. 22:1047 to the contrary, any health coverage plan specified in Subsection H of this Section which is issued for delivery, delivered, renewed, or otherwise contracted for in this state on or after January 1, 2009, shall provide coverage of prosthetic devices and prosthetic services as further provided in this Section. B. Eligibility and limits of coverage for prosthetic devices and prosthetic services shall be determined by the health coverage plan, based on medical necessity. Any denial or limit of coverage based on lack of medical necessity may be appealed in accordance with R.S. 22:1121 et seq. Such medical necessity determination shall consider information and recommendation from the treating physician in consultation with the insured, including the results of a functional limit test. Such test shall consider but not be limited to the following factors: (1) The insured's past history, including prior use of prosthetic devices if applicable. (2) The insured's current condition, including the status of the residual limb and the nature of other medical problems. (3) The insured's desire to ambulate, with respect to lower limb prosthetic devices, or maximize upper limb function, with respect to upper limb prosthetic devices. C. A health coverage plan may require prior authorization for prosthetic devices and prosthetic services in the same manner that prior authorization is required for any other covered benefit. D. A health coverage plan may impose co-payments, deductibles, or coinsurance amounts on prosthetic devices and prosthetic services. The co-payments shall not be greater than the co-payments that apply to other benefits under the plan. The repair and replacement of prosthetic devices also shall be covered subject to co-payments, coinsurance, and deductibles that are no more restrictive than the co-payments, coinsurance, and deductibles that apply to other benefits under the plan, unless necessitated by misuse or loss. E. A health coverage plan shall include a requirement that prosthetic devices be provided by an accredited facility and a requirement that prosthetic services be prescribed by a licensed physician and provided by an accredited facility. F. Coverage of prosthetic devices and prosthetic services may be made subject to but no more restrictive than the provisions of a health coverage plan that apply to other benefits under the plan. G.(1) A health coverage plan may apply an annual limit of benefits payable under this Section of no less than fifty thousand dollars per limb. (2) This Subsection does not prohibit a health benefit plan from providing coverage that is greater or more favorable to an insured than the requirements of this Subsection. (3) An insured may choose a prosthetic device that is priced higher than the benefit payable under the health benefit plan and may pay the difference between the price of the device and the benefit payable, without financial or contractual penalty to the provider of the device. H. As used in the Section: (1) "Accredited facility" means any entity that is accredited by the American Board for Certification in Orthotics Prosthetics and Pedorthics (ABC) or by the Board for Orthotist/Prosthetist Certification (BOC) and that provides prosthetic devices or prosthetic services. (2) "Health coverage plan" shall mean any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract or agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan and the Office of Group Benefits programs. (3) "Prosthetic device" or "prosthesis" means an artificial limb designed to maximize function, stability, and safety of the patient. Prosthetic device or prosthesis also means an artificial medical device that is not surgically implanted and that is used to replace a missing limb. The term does not include artificial eyes, ears, noses, dental appliances, ostomy products, or devices such as eyelashes or wigs. (4) "Prosthetic services" means the science and practice of evaluating, measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or servicing of a prosthesis through the replacement of external parts of a human body lost due to amputation or congenital deformities to restore function, cosmesis, or both. It shall also include any medically necessary clinical care. I. The provisions of this Section shall not apply to limited benefit health insurance policies or contracts. Acts 2008, No. 349, §1, eff. June 21, 2008; Acts 2010, No. 919, §1, eff. Jan. 1, 2011.