THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE BILL

INTRODUCED BY O'NEILL, MATZIE, BARRAR, BRIGGS, CALTAGIRONE, COHEN, D. COSTA, EVERETT, FLECK, GEIST, GEORGE, GOODMAN, HARKINS, HESS, JOSEPHS, KAVULICH, KIRKLAND, KORTZ, LONGIETTI, MAJOR, MILLARD, MOUL, MURT, D. O'BRIEN, PYLE, RAPP, READSHAW, REICHLEY, SCAVELLO, VULAKOVICH AND WATSON, FEBRUARY 23, 2011

REFERRED TO COMMITTEE ON INSURANCE, FEBRUARY 23, 2011  

AN ACT

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

act relating to insurance; amending, revising, and

consolidating the law providing for the incorporation of

insurance companies, and the regulation, supervision, and

protection of home and foreign insurance companies, Lloyds

associations, reciprocal and inter-insurance exchanges, and

fire insurance rating bureaus, and the regulation and

supervision of insurance carried by such companies,

associations, and exchanges, including insurance carried by

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

repealing existing laws," providing for reimbursement for

prosthetic devices.

The General Assembly finds and declares as follows:

(1)  Individuals with limb loss face many challenges.

Included in these challenges are the economic pressures

placed on these individuals and their families.

(2)  Individuals with limb loss need a prosthetic device

to continue to function daily by maintaining educational

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

provide for their own economic support and for their family.

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

needs of individuals with limb loss to be functioning,

contributing members of society.

(4)  The General Assembly recognizes that a prosthetic

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

loss and finds it necessary to require that health insurance

policies issued in this Commonwealth include such coverage.

The General Assembly of the Commonwealth of Pennsylvania

hereby enacts as follows:

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

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

section to read:

Section 635.6.  Reimbursement for Prosthetic Devices.--(a)  

Except to the extent already covered under another policy, any

individual or group health, sickness and accident insurance

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

forms of managed and capitated care plans and policies or

subscriber contract or certificate issued by any entity subject

to 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or

63 (relating to professional health services plan corporations)

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

"Health Maintenance Organization Act," or this act providing

hospital or medical and surgical coverage shall provide coverage

of prosthetic devices and components if prescribed by a health

care professional legally authorized to prescribe such items

under law. The benefits specified in this section may be

provided through a combination of policies, contracts,

certificates or riders, including major medical contracts.

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

to determine medical necessity and the eligibility of benefits

for prosthetic devices and components.

(2)  Coverage under this section shall also include the

fitting, repair or replacement of a prosthetic device or

component if the fitting, repair or replacement is determined to

be medically necessary. A fitting, repair or replacement

necessitated by the negligence of proper care and maintenance or

by an abusive act committed by the individual having the

prosthetic device shall not be covered.

(3)  A health care insurer may require that prosthetic

services be rendered by a provider that contracts with the

carrier and that a prosthetic device or component be provided by

a vendor designated by that insurer.

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

that is designed exclusively for athletic purposes.

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

copayment, coinsurance or deductible amounts imposed by an

entity subject to this section for similar coverages under the

same health insurance policy or contract.

(6)  The attending physician must certify the medical

necessity for a prosthetic device and component as a proposed

course of treatment.

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

have the meanings given to them in this subsection:

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

ensure the comfort and functioning of a prosthetic device.

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

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

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

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

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