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PRINTER'S NO. 3272
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No.
2399
Session of
2024
INTRODUCED BY SAPPEY, GAYDOS, MADDEN, HILL-EVANS, PROBST,
HANBIDGE, ROZZI, FLEMING, KHAN, SANCHEZ, HOWARD, PIELLI,
CONKLIN, FREEMAN AND OTTEN, JUNE 10, 2024
REFERRED TO COMMITTEE ON INSURANCE, JUNE 10, 2024
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," in casualty insurance, providing
for reimbursement for custom-fabricated devices or custom-
fitted devices.
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 635.9. Reimbursement for Custom-fabricated Devices
or Custom-fitted Devices.--(a) A health insurance policy
offered, issued or renewed in this Commonwealth shall provide
coverage for any custom-fabricated device or custom-fitted
device, including any component, if prescribed by a health care
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practitioner who is legally authorized to prescribe the device.
The following apply:
(1) The coverage for the device shall apply if the health
care practitioner determines that the device is medically
necessary for any of the following purposes:
(i) Completing activities of daily living or essential job-
related activities.
(ii) Performing physical activities, such as running,
biking, swimming or strength training.
(iii) Maximizing the enrollee's whole-body health or lower
or upper limb function.
(2) As follows:
(i) Subject to subparagraph (ii), the coverage for the
device shall include the fitting, repair or replacement of the
device if the health care practitioner determines that the
fitting, repair or replacement is medically necessary.
(ii) Subparagraph (i) shall not apply if the fitting, repair
or replacement of the device is necessitated by the enrollee's:
(A) negligence in properly caring for or maintaining the
device; or
(B) misuse or abuse of the device.
(b) A health insurer may require prior authorization to
determine medical necessity and the enrollee's eligibility for
benefits under this section.
(c) A health insurer may require that:
(1) A prosthesis or related service be rendered by a
provider that contracts with the health insurer.
(2) A prosthetic device or component be provided by a vendor
designated by the health insurer.
(d) Nothing in this section shall be construed to prevent
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the application of a provision in a health insurance policy
relating to a deductible, copayment or coinsurance.
(e) For coverage under this section to be operative, a
health care practitioner who is legally authorized to prescribe
a custom-fabricated device or custom-fitted device, including a
component, must certify the medical necessity for the device as
a proposed course of treatment.
(f) As used in this section:
"Activities of daily living" means activities such as eating,
drinking, ambulating, transferring in and out of a bed or chair,
toileting, bladder and bowel management, personal hygiene and
proper turning and positioning in a bed or chair.
"Component" means the materials and equipment needed to
ensure the comfort and functioning of a custom-fabricated device
or custom-fitted device.
"Custom-fabricated device" means a prosthesis, orthosis or
pedorthic device that is fabricated to comprehensive
measurements or a mold for use by a patient in accordance with a
prescription and which requires substantial clinical and
technical judgment in its design fabrication and fitting.
"Custom-fitted device" means a prefabricated prosthesis,
orthosis or pedorthic device to accommodate the patient's
measurement that is sized or modified for use by the patient in
accordance with a prescription and which requires substantial
clinical judgment and substantive alterations in its design for
appropriate use.
"Department" means the Insurance Department of the
Commonwealth.
"Enrollee" means a policyholder, subscriber or covered person
under a health insurance policy.
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"Health care practitioner" means an individual who is
authorized to practice some component of the healing arts by a
license, permit, certificate or registration issued by a
Commonwealth licensing agency or board.
"Health care service" means as defined in section 2102.
"Health insurance policy" means a policy, subscriber
contract, certificate or plan issued by a health insurer that
provides medical or health care coverage. The term does not
include any of the following:
(1) An accident only policy.
(2) A credit only policy.
(3) A long-term care or disability income policy.
(4) A specified disease policy.
(5) A Medicare supplement policy.
(6) A TRICARE policy, including a Civilian Health and
Medical Program of the Uniformed Services (CHAMPUS) supplement
policy.
(7) A fixed indemnity policy.
(8) A hospital indemnity policy.
(9) A dental only policy.
(10) A vision only policy.
(11) A workers' compensation policy.
(12) An automobile medical payment policy under 75 Pa.C.S.
(relating to vehicles).
(13) A homeowner's insurance policy.
(14) Any other similar policy providing for limited
benefits.
"Health insurer" means an entity licensed by the department
with accident and health authority to issue a health insurance
policy and is offered or governed under any of the following:
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(1) Section 630, Article XXIV or another provision of this
act.
(2) The act of December 29, 1972 (P.L.1701, No.364), known
as the Health Maintenance Organization Act.
(3) 40 Pa.C.S. Ch. 61 (relating to hospital plan
corporations) or 63 (relating to professional health services
plan corporations).
"MA or CHIP managed care plan" means as defined in section
2102.
"Orthosis" means a custom-fabricated or custom-fitted device
designed to externally provide support, alignment or prevention
to the body or a limb for the purposes of correcting or
alleviating a neuromuscular or musculoskeletal disease, injury
or deformity.
"Pedorthic device" means as follows:
(1) Therapeutic shoes, a shoe modification made for
therapeutic purposes, a partial foot prosthesis, a foot orthosis
or a below-the-knee pedorthic modality.
(2) The term does not include:
(i) A nontherapeutic, accommodative inlay or nontherapeutic
accommodative footwear, regardless of the method of manufacture.
(ii) Unmodified, nontherapeutic over-the-counter shoes.
(iii) A prefabricated unmodified or unmodifiable foot care
or footwear product.
"Prior authorization" means a prospective utilization review
performed by a health insurer or MA or CHIP managed care plan,
or by a utilization review entity acting on behalf of a health
insurer or MA or CHIP managed care plan, of all reasonably
necessary supporting information that occurs prior to the
delivery or provision of a health care service and results in a
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decision to approve or deny payment for the health care service.
The term includes step therapy and step therapy exception
requests.
"Prosthesis" means a custom-designed, custom-fabricated,
custom-fitted or custom-modified device to replace an absent
external limb for purposes of restoring physiological function
that is not surgically implanted. The term does not include
artificial eyes, ears, fingers or toes, dental appliances,
cosmetic devices, such as artificial breasts, eyelashes or wigs,
or other devices that do not have a significant impact on the
musculoskeletal functions of the body.
"Step therapy" means as defined in section 2102.
"Utilization review" means as defined in section 2102.
"Utilization review entity" means as defined in section 2102.
Section 2. This act shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the Federal Government
or the Insurance Department, this act shall apply to any
policy for which a form or rate is first filed on or after
the effective date of this paragraph.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the Federal
Government or the Insurance Department, this act shall apply
to any policy issued or renewed on or after 180 days after
the effective date of this paragraph.
Section 3. This act shall take effect in 60 days.
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