PRINTER'S NO.  1593

  

THE GENERAL ASSEMBLY OF PENNSYLVANIA

  

HOUSE BILL

 

No.

1333

Session of

2009

  

  

INTRODUCED BY O'NEILL, MATZIE, BARRAR, BELFANTI, BEYER, COHEN, D. COSTA, CREIGHTON, DALEY, EVERETT, FABRIZIO, GEIST, GEORGE, HENNESSEY, HESS, HORNAMAN, JOSEPHS, KULA, MAJOR, MELIO, MILLARD, MURPHY, MURT, OBERLANDER, D. O'BRIEN, PICKETT, RAPP, READSHAW, REICHLEY, SCAVELLO, SEIP, SIPTROTH, K. SMITH, VULAKOVICH, WATSON AND YOUNGBLOOD, APRIL 22, 2009

  

  

REFERRED TO COMMITTEE ON HEALTH AND HUMAN SERVICES, APRIL 22, 2009  

  

  

  

AN ACT

  

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Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An

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act relating to insurance; amending, revising, and

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consolidating the law providing for the incorporation of

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insurance companies, and the regulation, supervision, and

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protection of home and foreign insurance companies, Lloyds

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associations, reciprocal and inter-insurance exchanges, and

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fire insurance rating bureaus, and the regulation and

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supervision of insurance carried by such companies,

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associations, and exchanges, including insurance carried by

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the State Workmen's Insurance Fund; providing penalties; and

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repealing existing laws," providing for reimbursement for

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prosthetic devices.

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The General Assembly finds and declares as follows:

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(1)  Individuals with limb loss face many challenges.

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Included in these challenges are the economic pressures

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placed on these individuals and their families.

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(2)  Individuals with limb loss need a prosthetic device

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to continue to function daily by maintaining educational

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activities or by being an integral part of the work force to

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provide for their own economic support and for their family.

 


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(3)  The intent of this act is to assist the special

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needs of individuals with limb loss to be functioning,

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contributing members of society.

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(4)  The General Assembly recognizes that a prosthetic

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device is critical to the well-being of individuals with limb

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loss and finds it necessary to require that health insurance

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policies issued in this Commonwealth include such coverage.

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The General Assembly of the Commonwealth of Pennsylvania

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hereby enacts as follows:

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Section 1.  The act of May 17, 1921 (P.L.682, No.284), known

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as The Insurance Company Law of 1921, is amended by adding a

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section to read:

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Section 635.4.  Reimbursement for Prosthetic Devices.--(a)  

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Except to the extent already covered under another policy, any

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individual or group health, sickness and accident insurance

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policy, group health insurance plans/policies, and all other

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forms of managed/capitated care plans/policies or subscriber

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contract or certificate issued by any entity subject to 40

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Pa.C.S. Ch. 61 (relating to hospital plan corporations) or 63

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(relating to professional health services plan corporations) or

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the act of December 29, 1972 (P.L.1701, No.364), known as the

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"Health Maintenance Organization Act," or this act providing

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hospital or medical/surgical coverage shall provide coverage of

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prosthetic devices and components if prescribed by a health care

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professional legally authorized to prescribe such items under

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law. The benefits specified in this section may be provided

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through a combination of policies, contracts, certificates or

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riders, including major medical contracts.

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(b)  (1)  A health care insurer may require preauthorization

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to determine medical necessity and the eligibility of benefits

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for prosthetic devices and components.

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(2)  Coverage under this section shall also include the

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fitting, repair or replacement of a prosthetic device and/or

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component if the fitting, repair or replacement is determined to

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be medically necessary. A fitting, repair or replacement

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necessitated by the negligence of proper care and maintenance or

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by an abusive act committed by the individual having the

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prosthetic device shall not be covered.

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(3)  A health care insurer may require that prosthetic

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services be rendered by a provider that contracts with the

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carrier and that a prosthetic device or component be provided by

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a vendor designated by that insurer.

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(4)  Coverage shall not be required for a prosthetic device

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that is designed exclusively for athletic purposes.

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(5)  Coverage under this section shall remain subject to any

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copayment, coinsurance or deductible amounts imposed by an

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entity subject to this section for similar coverages under the

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same health insurance policy or contract.

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(6)  The attending physician must certify the medical

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necessity for a prosthetic device and component as a proposed

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course of treatment.

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(c)  When used in this section, the following terms shall

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have the meanings given to them in this subsection:

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(1)  "Component" means the materials and equipment needed to

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ensure the comfort and functioning of a prosthetic device.

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(2)  "Limb" means an arm, a hand, a leg, a foot or any

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portion of an arm, a hand, a leg or a foot.

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(3)  "Prosthetic device" means an artificial device to

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replace a limb in whole or in part, including components.

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Section 2.  This act shall take effect in 60 days.

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