CHAPTER 24.2. COVERAGE FOR PROSTHETIC DEVICES
IC 27-8-24.2
Chapter 24.2. Coverage for Prosthetic Devices
IC 27-8-24.2-1
"Insured"
Sec. 1. As used in this chapter, "insured" means an individual whois entitled to coverage under a policy of accident and sicknessinsurance.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-2
"Orthotic device"
Sec. 2. As used in this chapter, "orthotic device" means amedically necessary custom fabricated brace or support that isdesigned as a component of a prosthetic device.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-3
"Policy of accident and sickness insurance"
Sec. 3. (a) As used in this chapter, "policy of accident andsickness insurance" has the meaning set forth in IC 27-8-5-1.
(b) The term does not include the following:
(1) Accident only, credit, dental, vision, Medicare, Medicaresupplement, long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Automobile medical payment insurance.
(4) A specified disease policy.
(5) A limited benefit health insurance policy.
(6) A short term insurance plan that:
(A) may not be renewed; and
(B) has a duration of not more than six (6) months.
(7) A policy that provides a stipulated daily, weekly, or monthlypayment to an insured during hospital confinement, withoutregard to the actual expense of the confinement.
(8) Worker's compensation or similar insurance.
(9) A student health insurance policy.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-4
"Prosthetic device"
Sec. 4. As used in this chapter, "prosthetic device" means anartificial leg or arm.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-5
Coverage required
Sec. 5. A policy of accident and sickness insurance must providecoverage for orthotic devices and prosthetic devices, includingrepairs or replacements, that:
(1) are provided or performed by a person that is: (A) accredited as required under 42 U.S.C. 1395m(a)(20); or
(B) a qualified practitioner (as defined in 42 U.S.C.1395m(h)(1)(F)(iii));
(2) are determined by the insured's physician to be medicallynecessary to restore or maintain the insured's ability to performactivities of daily living or essential job related activities; and
(3) are not solely for comfort or convenience.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-6
Coverage and reimbursement
Sec. 6. The:
(1) coverage required under section 5 of this chapter must beequal to the coverage that is provided for the same device,repair, or replacement under the federal Medicare program (42U.S.C. 1395 et seq.); and
(2) reimbursement under the coverage required under section 5of this chapter must be equal to the reimbursement that isprovided for the same device, repair, or replacement under thefederal Medicare reimbursement schedule, unless a differentreimbursement rate is negotiated.
This section does not require a deductible under a policy of accidentand sickness insurance to be equal to a deductible under the federalMedicare program.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-7
Comparison to other benefits
Sec. 7. Except as provided in sections 8 and 9 of this chapter, thecoverage required under section 5 of this chapter:
(1) may be subject to; and
(2) may not be more restrictive than;
the provisions that apply to other benefits under the policy ofaccident and sickness insurance.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-8
Continued medical necessity review
Sec. 8. The coverage required under section 5 of this chapter maybe subject to utilization review, including periodic review, of thecontinued medical necessity of the benefit.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-9
Lifetime maximum coverage limitation
Sec. 9. Any lifetime maximum coverage limitation that applies toprosthetic devices and orthotic devices:
(1) must not be included in; and
(2) must be equal to;
the lifetime maximum coverage limitation that applies to all other
items and services generally under the policy of accident andsickness insurance.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-10
Deductible, copayment, or coinsurance requirements
Sec. 10. For purposes of this section, "items and services" doesnot include preventive services for which coverage is provided undera high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26U.S.C. 223(c)(2)). The coverage required under section 5 of thischapter may not be subject to a deductible, copayment, orcoinsurance provision that is less favorable to an insured than thedeductible, copayment, or coinsurance provisions that apply to otheritems and services generally under the policy of accident andsickness insurance.
As added by P.L.109-2008, SEC.2.