§ 27-19-58 - Reimbursement for orthotics and prosthetic services. - Rhode Island Statutes

SECTION 27-19-58

   § 27-19-58  Reimbursement for orthotics andprosthetic services. – (a) As used in this section:

   (1) "Federal reimbursement rates" means the current listedfee schedule from the Centers for Medicare and Medicaid Services, listing thecurrent Healthcare Common Procedure Coding system (HCPCS) and the correspondingreimbursement rates.

   (2) "Orthosis" means a custom fabricated brace or supportthat is designed based on medical necessity. Orthosis does not includeprefabricated or direct-formed orthotic devices, as defined in this section, orany of the following assistive technology devices: commercially available kneeorthoses used following injury or surgery; spastic muscle-tone inhibitingorthoses; upper extremity adaptive equipment; finger splints; hand splints;wrist gauntlets; face masks used following burns; wheelchair seating that is anintegral part of the wheelchair and not worn by the patient independent of thewheelchair; fabric or elastic supports; corsets; low-temperature formed plasticsplints; trusses; elastic hose; canes; crutches; cervical collars; dentalappliances; and other similar devices as determined by the director of thedepartment of health, such as those commonly carried in stock by a pharmacy,department store, corset shop, or surgical supply facility.

   (3) "Orthotics" means the science and practice of evaluatingmeasuring, designing, fabricating, assembling, fitting, adjusting or servicing,as well as providing the initial training necessary to accomplish the fittingof, an orthosis for the support, correction, or alleviation of neuromuscular ormusculoskeletal dysfunction, disease, injury or deformity. The practice oforthotics encompasses evaluation, treatment, and consultation; with basicobservational gait and postural analysis, orthotists assess and design orthosesto maximize function and provide not only the support but the alignmentnecessary to either prevent or correct a deformity or to improve the safety andefficiency of mobility or locomotion or both. Orthotic practice includesproviding continuing patient care in order to assess its effect on thepatient's tissues and to assure proper fit and function of the orthotic deviceby periodic evaluation.

   (4) "Prosthesis" means an artificial limb that is alignableor, in lower-extremity applications capable of weight bearing. Prosthesis meansan artificial medical device that is not surgically implanted and that is usedto replace a missing limb, appendage, or other external human body partincluding an artificial limb, hand, or foot. The term does not includeartificial eyes, ears, noses, dental appliances, osotmy products, or devicessuch as eyelashes or wigs.

   (5) "Prosthetics" means the science and practice ofevaluation, measuring, designing, fabricating, assembling, fitting, aligning,adjusting or servicing, as well as providing the initial training necessary toaccomplish the fitting of, a prosthesis through the replacement of externalparts of a human body lost due to amputation or congenital deformities orabsences. The practice of prosthetics also includes the generation of an image,form, or mold that replicates the patient's body or body segment and thatrequires rectification of dimensions, contours and volumes for use in thedesign and fabrication of a socket to accept a residual anatomic limb to, inturn, create an artificial appendage that is designed either to support bodyweight or to improve or restore function or cosmesis, or both. Involved in thepractice of prosthetics is observational gait analysis and clinical assessmentof the requirements necessary to refine and mechanically fix the relativeposition of various parts of the prosthesis to maximize function, stability,and safety of the patient. The practice of prosthetics includes providing andcontinuing patient care in order to assess the prosthetic device's effect onthe patient's tissues and to assure proper fit and function of the prostheticdevice by periodic evaluation.

   (6) "Private insurance company" means any insurance company,or management company hired by an insurance company, who is any of thefollowing:

   (i) based in the state of Rhode Island; or

   (ii) provides coverage for citizens for the state of RhodeIsland; or

   (iii) allows subscribing patients to seek prosthetic ororthotic services in the state of Rhode Island.

   (b) Every individual or group health insurance contract, planor policy delivered, issued for delivery or renewed in this state on or afterJanuary 1, 2006, which provides medical coverage that includes coverage forphysician services in a physician's office and every policy, which providesmajor medical or similar comprehensive type coverage shall provide coverage forbenefits for orthotic and prosthetic devices that equal those benefits providedfor under federal laws for health insurance for the aged and disabled pursuantto 42 U.S.C. sections 1395K, 13951 and 1395M and 42 CFR 414.202, 414.210,414.228, and 410.100 as applicable to this section.

   (c) A health insurance contract, plan or policy may requireprior authorization for orthotic and prosthetic devices in the same manner thatprior authorization is required for any other covered benefit.

   (d) Covered benefits for orthotic or prosthetic devices shallbe limited to the most appropriate model that adequately meets the medicalneeds of the patient as determined by the insured's treating physician.

   (e) The repair and replacement of orthotic or prostheticdevices also shall be covered subject to co-payments and deductibles, unlessnecessitated by misuse or loss.

   (f) An insurer may require, if coverage is provided through amanaged care plan, that benefits mandated pursuant to this section be coveredbenefits only if the orthotic or prosthetic devices are provided by a vendorand orthotic or prosthetic services are rendered by a provider who is licensedby the state of Rhode Island to provide orthotics and prosthetics.