§ 38.2-3418.15. Coverage for prosthetic devices and components.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue individual or group accident and sickness insurance policies providinghospital, medical and surgical, or major medical coverage on anexpense-incurred basis; each corporation providing individual or groupaccident and sickness subscription contracts; and each health maintenanceorganization providing a health care plan for health care services shalloffer and make available coverage for medically necessary prosthetic devices,their repair, fitting, replacement, and components, as follows:
1. As used in this section:
"Component" means the materials and equipment needed to ensure the comfortand functioning of a prosthetic device.
"Limb" means an arm, a hand, a leg, a foot, or any portion of an arm, ahand, a leg, or a foot.
"Prosthetic device" means an artificial device to replace, in whole or inpart, a limb.
2. Prosthetic device coverage does not include repair and replacement due toenrollee neglect, misuse, or abuse. Coverage also does not include prostheticdevices designed primarily for an athletic purpose.
3. An insurer shall not impose any annual or lifetime dollar maximum oncoverage for prosthetic devices other than an annual or lifetime dollarmaximum that applies in the aggregate to all items and services covered underthe policy. The coverage may be made subject to, and no more restrictivethan, the provisions of a health insurance policy that apply to otherbenefits under the policy.
4. An insurer shall not apply amounts paid for prosthetic devices to anyannual or lifetime dollar maximum applicable to other durable medicalequipment covered under the policy other than an annual or lifetime dollarmaximum that applies in the aggregate to all items and services covered underthe policy.
5. No insurer, corporation, or health maintenance organization shall imposeupon any person receiving benefits pursuant to this section any coinsurancein excess of 30 percent of the carrier's allowable charge for such prostheticdevice or services when such device or service is provided by an in-networkprovider.
6. An insurer, corporation, or health maintenance organization may requirepreauthorization to determine medical necessity and the eligibility ofbenefits for prosthetic devices and components, in the same manner that priorauthorization is required for any other covered benefit.
B. The requirements of this section shall apply to all insurance policies,contracts, and plans delivered, issued for delivery, reissued, or extended inthe Commonwealth on and after January 1, 2010, or at any time thereafter whenany term of the policy, contract, or plan is changed or any premiumadjustment is made.
C. This section shall not apply to short-term travel, accident-only, limitedor specified disease, or individual conversion policies or contracts, nor topolicies or contracts designed for issuance to persons eligible for coverageunder Title XVIII of the Social Security Act, known as Medicare, or any othersimilar coverage under state or federal governmental plans.
§ 38.2-3418.15. Coverage for prosthetic devices and components.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue individual or group accident and sickness insurance policies providinghospital, medical and surgical, or major medical coverage on anexpense-incurred basis; each corporation providing individual or groupaccident and sickness subscription contracts; and each health maintenanceorganization providing a health care plan for health care services shalloffer and make available coverage for medically necessary prosthetic devices,their repair, fitting, replacement, and components, as follows:
1. As used in this section:
"Component" means the materials and equipment needed to ensure the comfortand functioning of a prosthetic device.
"Limb" means an arm, a hand, a leg, a foot, or any portion of an arm, ahand, a leg, or a foot.
"Prosthetic device" means an artificial device to replace, in whole or inpart, a limb.
2. Prosthetic device coverage does not include repair and replacement due toenrollee neglect, misuse, or abuse. Coverage also does not include prostheticdevices designed primarily for an athletic purpose.
3. An insurer shall not impose any annual or lifetime dollar maximum oncoverage for prosthetic devices other than an annual or lifetime dollarmaximum that applies in the aggregate to all items and services covered underthe policy. The coverage may be made subject to, and no more restrictivethan, the provisions of a health insurance policy that apply to otherbenefits under the policy.
4. An insurer shall not apply amounts paid for prosthetic devices to anyannual or lifetime dollar maximum applicable to other durable medicalequipment covered under the policy other than an annual or lifetime dollarmaximum that applies in the aggregate to all items and services covered underthe policy.
5. No insurer, corporation, or health maintenance organization shall imposeupon any person receiving benefits pursuant to this section any coinsurancein excess of 30 percent of the carrier's allowable charge for such prostheticdevice or services when such device or service is provided by an in-networkprovider.
6. An insurer, corporation, or health maintenance organization may requirepreauthorization to determine medical necessity and the eligibility ofbenefits for prosthetic devices and components, in the same manner that priorauthorization is required for any other covered benefit.
B. The requirements of this section shall apply to all insurance policies,contracts, and plans delivered, issued for delivery, reissued, or extended inthe Commonwealth on and after January 1, 2010, or at any time thereafter whenany term of the policy, contract, or plan is changed or any premiumadjustment is made.
C. This section shall not apply to short-term travel, accident-only, limitedor specified disease, or individual conversion policies or contracts, nor topolicies or contracts designed for issuance to persons eligible for coverageunder Title XVIII of the Social Security Act, known as Medicare, or any othersimilar coverage under state or federal governmental plans.
§ 38.2-3418.15. Coverage for prosthetic devices and components.
A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing toissue individual or group accident and sickness insurance policies providinghospital, medical and surgical, or major medical coverage on anexpense-incurred basis; each corporation providing individual or groupaccident and sickness subscription contracts; and each health maintenanceorganization providing a health care plan for health care services shalloffer and make available coverage for medically necessary prosthetic devices,their repair, fitting, replacement, and components, as follows:
1. As used in this section:
"Component" means the materials and equipment needed to ensure the comfortand functioning of a prosthetic device.
"Limb" means an arm, a hand, a leg, a foot, or any portion of an arm, ahand, a leg, or a foot.
"Prosthetic device" means an artificial device to replace, in whole or inpart, a limb.
2. Prosthetic device coverage does not include repair and replacement due toenrollee neglect, misuse, or abuse. Coverage also does not include prostheticdevices designed primarily for an athletic purpose.
3. An insurer shall not impose any annual or lifetime dollar maximum oncoverage for prosthetic devices other than an annual or lifetime dollarmaximum that applies in the aggregate to all items and services covered underthe policy. The coverage may be made subject to, and no more restrictivethan, the provisions of a health insurance policy that apply to otherbenefits under the policy.
4. An insurer shall not apply amounts paid for prosthetic devices to anyannual or lifetime dollar maximum applicable to other durable medicalequipment covered under the policy other than an annual or lifetime dollarmaximum that applies in the aggregate to all items and services covered underthe policy.
5. No insurer, corporation, or health maintenance organization shall imposeupon any person receiving benefits pursuant to this section any coinsurancein excess of 30 percent of the carrier's allowable charge for such prostheticdevice or services when such device or service is provided by an in-networkprovider.
6. An insurer, corporation, or health maintenance organization may requirepreauthorization to determine medical necessity and the eligibility ofbenefits for prosthetic devices and components, in the same manner that priorauthorization is required for any other covered benefit.
B. The requirements of this section shall apply to all insurance policies,contracts, and plans delivered, issued for delivery, reissued, or extended inthe Commonwealth on and after January 1, 2010, or at any time thereafter whenany term of the policy, contract, or plan is changed or any premiumadjustment is made.
C. This section shall not apply to short-term travel, accident-only, limitedor specified disease, or individual conversion policies or contracts, nor topolicies or contracts designed for issuance to persons eligible for coverageunder Title XVIII of the Social Security Act, known as Medicare, or any othersimilar coverage under state or federal governmental plans.
