HOUSE BILL No. 4898

 

June 12, 2007, Introduced by Reps. Wojno, Accavitti, Miller and Polidori and referred to the Committee on Insurance.

 

     A bill to amend 1956 PA 218, entitled

 

"The insurance code of 1956,"

 

(MCL 500.100 to 500.8302) by adding section 3406s.

 

THE PEOPLE OF THE STATE OF MICHIGAN ENACT:

 

     Sec. 3406s. (1) An expense-incurred hospital, medical, or

 

surgical policy or certificate delivered, issued for delivery, or

 

renewed in this state and a health maintenance organization group

 

or individual contract shall include coverage for prosthetics and

 

orthotics that, at a minimum, equals the prosthetics and orthotics

 

coverage provided for under 42 USC 1395k, 1395l, and 1395n and 42

 

CFR 410.100, 414.202, 414.210, and 414.228. Coverage shall include

 

replacement for the prosthetic or orthotic if required because of a

 

change in the member's physical condition and for repair or

 

replacement if determined appropriate by the member's treating

 


physician. Coverage may be limited to the most appropriate model

 

that adequately meets the medical needs of the member as determined

 

by the member's treating physician.

 

     (2) An insurer and a health maintenance organization may

 

require prior authorization for prosthetics and orthotics in the

 

same manner that prior authorization is required for any other

 

covered benefit. An insurer and a health maintenance organization

 

may impose copayments and coinsurance amounts on prosthetics and

 

orthotics not to exceed the copayment and coinsurance amounts

 

imposed for prosthetics and orthotics under part B of medicare, 42

 

USC 1395j to 1395w-4. An insurer and a health maintenance

 

organization shall reimburse for prosthetics and orthotics at no

 

less than the fee schedule for prosthetics and orthotics under the

 

medical reimbursement fee schedule established by the centers for

 

medicare and medicaid services based on the health care common

 

procedure coding system. An insurer and a health maintenance

 

organization shall not impose any annual or lifetime dollar maximum

 

on prosthetics and orthotics coverage other than an annual or

 

lifetime dollar maximum that applies in the aggregate to all terms

 

and services covered under the policy, certificate, or contract.

 

     (3) As used in this section:

 

     (a) "Orthotics" means all services requiring custom orthoses.

 

     (b) "Prosthetics" means external extremity prosthetics for the

 

appendicular skeleton.

 

     Enacting section 1. This amendatory act takes effect 180 days

 

after the date it is enacted.