State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1371-coverage-for-certain-prosthetic-devices-orthotic-devices-and-related-services
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES, ORTHOTIC
DEVICES, AND RELATED SERVICES
Sec. 1371.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual entitled to coverage under a
health benefit plan.
(2) "Orthotic device" means a custom-fitted or custom-fabricated
medical device that is applied to a part of the human body to
correct a deformity, improve function, or relieve symptoms of a
disease.
(3) "Prosthetic device" means an artificial device designed to
replace, wholly or partly, an arm or leg.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including a small employer
health benefit plan written under Chapter 1501 or coverage
provided by a health group cooperative under Subchapter B of that
chapter, that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or
similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter
842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium company operating under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under Chapter
843;
(8) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1551, 1575, 1579,
or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579; and
(4) basic coverage under Chapter 1601.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES,
ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit
plan must provide coverage for prosthetic devices, orthotic
devices, and professional services related to the fitting and use
of those devices that equals the coverage provided under federal
laws for health insurance for the aged and disabled under
Sections 1832, 1833, and 1834, Social Security Act (42 U.S.C.
Sections 1395k, 1395l, and 1395m), and 42 C.F.R. Sections
410.100, 414.202, 414.210, and 414.228, as applicable.
(b) Covered benefits under this chapter are limited to the most
appropriate model of prosthetic device or orthotic device that
adequately meets the medical needs of the enrollee as determined
by the enrollee's treating physician or podiatrist and
prosthetist or orthotist, as applicable.
(c) Subject to applicable copayments and deductibles, the repair
and replacement of a prosthetic device or orthotic device is a
covered benefit under this chapter unless the repair or
replacement is necessitated by misuse or loss by the enrollee.
(d) Coverage required under this section:
(1) must be provided in a manner determined to be appropriate in
consultation with the treating physician or podiatrist and
prosthetist or orthotist, as applicable, and the enrollee;
(2) may be subject to annual deductibles, copayments, and
coinsurance that are consistent with annual deductibles,
copayments, and coinsurance required for other coverage under the
health benefit plan; and
(3) may not be subject to annual dollar limits.
(e) Covered benefits under this chapter may be provided by a
pharmacy that has employees who are qualified under the Medicare
system and applicable Medicaid regulations to service and bill
for orthotic services. This chapter does not preclude a pharmacy
from being reimbursed by a health benefit plan for the provision
of orthotic services.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.004. PREAUTHORIZATION. A health benefit plan may
require prior authorization for a prosthetic device or an
orthotic device in the same manner that the health benefit plan
requires prior authorization for any other covered benefit.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan
provider may require that, if coverage is provided through a
managed care plan, the benefits mandated under this chapter are
covered benefits only if the prosthetic devices or orthotic
devices are provided by a vendor or a provider, and related
services are rendered by a provider, that contracts with or is
designated by the health benefit plan provider. If the health
benefit plan provider provides in-network and out-of-network
services, the coverage for prosthetic devices or orthotic devices
provided through out-of-network services must be comparable to
that provided through in-network services.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
State Codes and Statutes
Statutes > Texas > Insurance-code > Title-8-health-insurance-and-other-health-coverages > Chapter-1371-coverage-for-certain-prosthetic-devices-orthotic-devices-and-related-services
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES, ORTHOTIC
DEVICES, AND RELATED SERVICES
Sec. 1371.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual entitled to coverage under a
health benefit plan.
(2) "Orthotic device" means a custom-fitted or custom-fabricated
medical device that is applied to a part of the human body to
correct a deformity, improve function, or relieve symptoms of a
disease.
(3) "Prosthetic device" means an artificial device designed to
replace, wholly or partly, an arm or leg.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including a small employer
health benefit plan written under Chapter 1501 or coverage
provided by a health group cooperative under Subchapter B of that
chapter, that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or
similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter
842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium company operating under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under Chapter
843;
(8) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1551, 1575, 1579,
or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579; and
(4) basic coverage under Chapter 1601.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES,
ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit
plan must provide coverage for prosthetic devices, orthotic
devices, and professional services related to the fitting and use
of those devices that equals the coverage provided under federal
laws for health insurance for the aged and disabled under
Sections 1832, 1833, and 1834, Social Security Act (42 U.S.C.
Sections 1395k, 1395l, and 1395m), and 42 C.F.R. Sections
410.100, 414.202, 414.210, and 414.228, as applicable.
(b) Covered benefits under this chapter are limited to the most
appropriate model of prosthetic device or orthotic device that
adequately meets the medical needs of the enrollee as determined
by the enrollee's treating physician or podiatrist and
prosthetist or orthotist, as applicable.
(c) Subject to applicable copayments and deductibles, the repair
and replacement of a prosthetic device or orthotic device is a
covered benefit under this chapter unless the repair or
replacement is necessitated by misuse or loss by the enrollee.
(d) Coverage required under this section:
(1) must be provided in a manner determined to be appropriate in
consultation with the treating physician or podiatrist and
prosthetist or orthotist, as applicable, and the enrollee;
(2) may be subject to annual deductibles, copayments, and
coinsurance that are consistent with annual deductibles,
copayments, and coinsurance required for other coverage under the
health benefit plan; and
(3) may not be subject to annual dollar limits.
(e) Covered benefits under this chapter may be provided by a
pharmacy that has employees who are qualified under the Medicare
system and applicable Medicaid regulations to service and bill
for orthotic services. This chapter does not preclude a pharmacy
from being reimbursed by a health benefit plan for the provision
of orthotic services.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.004. PREAUTHORIZATION. A health benefit plan may
require prior authorization for a prosthetic device or an
orthotic device in the same manner that the health benefit plan
requires prior authorization for any other covered benefit.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan
provider may require that, if coverage is provided through a
managed care plan, the benefits mandated under this chapter are
covered benefits only if the prosthetic devices or orthotic
devices are provided by a vendor or a provider, and related
services are rendered by a provider, that contracts with or is
designated by the health benefit plan provider. If the health
benefit plan provider provides in-network and out-of-network
services, the coverage for prosthetic devices or orthotic devices
provided through out-of-network services must be comparable to
that provided through in-network services.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
State Codes and Statutes
Statutes >
Texas >
Insurance-code >
Title-8-health-insurance-and-other-health-coverages >
Chapter-1371-coverage-for-certain-prosthetic-devices-orthotic-devices-and-related-services INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE E. BENEFITS PAYABLE UNDER HEALTH COVERAGES
CHAPTER 1371. COVERAGE FOR CERTAIN PROSTHETIC DEVICES, ORTHOTIC
DEVICES, AND RELATED SERVICES
Sec. 1371.001. DEFINITIONS. In this chapter:
(1) "Enrollee" means an individual entitled to coverage under a
health benefit plan.
(2) "Orthotic device" means a custom-fitted or custom-fabricated
medical device that is applied to a part of the human body to
correct a deformity, improve function, or relieve symptoms of a
disease.
(3) "Prosthetic device" means an artificial device designed to
replace, wholly or partly, an arm or leg.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.002. APPLICABILITY OF CHAPTER. (a) This chapter
applies only to a health benefit plan, including a small employer
health benefit plan written under Chapter 1501 or coverage
provided by a health group cooperative under Subchapter B of that
chapter, that provides benefits for medical or surgical expenses
incurred as a result of a health condition, accident, or
sickness, including an individual, group, blanket, or franchise
insurance policy or insurance agreement, a group hospital service
contract, or an individual or group evidence of coverage or
similar coverage document that is offered by:
(1) an insurance company;
(2) a group hospital service corporation operating under Chapter
842;
(3) a fraternal benefit society operating under Chapter 885;
(4) a stipulated premium company operating under Chapter 884;
(5) a reciprocal exchange operating under Chapter 942;
(6) a Lloyd's plan operating under Chapter 941;
(7) a health maintenance organization operating under Chapter
843;
(8) a multiple employer welfare arrangement that holds a
certificate of authority under Chapter 846; or
(9) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844.
(b) Notwithstanding any provision in Chapter 1551, 1575, 1579,
or 1601 or any other law, this chapter applies to:
(1) a basic coverage plan under Chapter 1551;
(2) a basic plan under Chapter 1575;
(3) a primary care coverage plan under Chapter 1579; and
(4) basic coverage under Chapter 1601.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.003. REQUIRED COVERAGE FOR PROSTHETIC DEVICES,
ORTHOTIC DEVICES, AND RELATED SERVICES. (a) A health benefit
plan must provide coverage for prosthetic devices, orthotic
devices, and professional services related to the fitting and use
of those devices that equals the coverage provided under federal
laws for health insurance for the aged and disabled under
Sections 1832, 1833, and 1834, Social Security Act (42 U.S.C.
Sections 1395k, 1395l, and 1395m), and 42 C.F.R. Sections
410.100, 414.202, 414.210, and 414.228, as applicable.
(b) Covered benefits under this chapter are limited to the most
appropriate model of prosthetic device or orthotic device that
adequately meets the medical needs of the enrollee as determined
by the enrollee's treating physician or podiatrist and
prosthetist or orthotist, as applicable.
(c) Subject to applicable copayments and deductibles, the repair
and replacement of a prosthetic device or orthotic device is a
covered benefit under this chapter unless the repair or
replacement is necessitated by misuse or loss by the enrollee.
(d) Coverage required under this section:
(1) must be provided in a manner determined to be appropriate in
consultation with the treating physician or podiatrist and
prosthetist or orthotist, as applicable, and the enrollee;
(2) may be subject to annual deductibles, copayments, and
coinsurance that are consistent with annual deductibles,
copayments, and coinsurance required for other coverage under the
health benefit plan; and
(3) may not be subject to annual dollar limits.
(e) Covered benefits under this chapter may be provided by a
pharmacy that has employees who are qualified under the Medicare
system and applicable Medicaid regulations to service and bill
for orthotic services. This chapter does not preclude a pharmacy
from being reimbursed by a health benefit plan for the provision
of orthotic services.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.004. PREAUTHORIZATION. A health benefit plan may
require prior authorization for a prosthetic device or an
orthotic device in the same manner that the health benefit plan
requires prior authorization for any other covered benefit.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
Sec. 1371.005. MANAGED CARE PLAN. A health benefit plan
provider may require that, if coverage is provided through a
managed care plan, the benefits mandated under this chapter are
covered benefits only if the prosthetic devices or orthotic
devices are provided by a vendor or a provider, and related
services are rendered by a provider, that contracts with or is
designated by the health benefit plan provider. If the health
benefit plan provider provides in-network and out-of-network
services, the coverage for prosthetic devices or orthotic devices
provided through out-of-network services must be comparable to
that provided through in-network services.
Added by Acts 2009, 81st Leg., R.S., Ch.
30, Sec. 1, eff. September 1, 2009.
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