PRINTER'S NO. 277
THE GENERAL ASSEMBLY OF PENNSYLVANIA
SENATE BILL
No.
289
Session of
2021
INTRODUCED BY MENSCH, REGAN, J. WARD, COSTA, BLAKE, CAPPELLETTI,
COLLETT, FONTANA, SANTARSIERO AND TARTAGLIONE,
FEBRUARY 26, 2021
REFERRED TO BANKING AND INSURANCE, FEBRUARY 26, 2021
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 prosthetic 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 635.8. Reimbursement for Prosthetic Devices.--(a)
Except to the extent already covered under another policy, an
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
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subscriber contracts or certificates 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
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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) As used in this section:
(1) "Component" means the materials and equipment needed to
ensure the comfort and functioning of a prosthetic device.
(2) "Limb" means an arm, hand, leg or foot or any portion of
an arm, hand, leg or 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.
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