RD56 - Senate Bill 931 (2007): Mandated Coverage for Prosthetic Devices and Components


Executive Summary:
The Senate Committee on Commerce and Labor referred Senate Bill 931 to the Advisory Commission during the 2007 Session of the General Assembly. Senate Bill 931 was introduced by Senator Patricia Ticer.

The bill requires insurers proposing to issue individual or group accident and sickness policies providing hospital, medical and surgical, or major medical coverage on an expense-incurred basis, corporations providing individual or group subscription contracts; and HMOs providing health care plans for health care plans to provide coverage for the cost of prosthetic devices and components, if the treating physician certifies that the medical necessity of the prosthetic device and components as a proposed course of treatment, at a minimum, equals the coverage provided under the federal Medicare program.

The bill defines “component” as the materials and equipment needed to ensure the comfort and functioning of a prosthetic device. “Limb” is defined as an arm, hand, leg, foot, or any portion of an arm, hand, leg, or foot. “Prosthetic device” is defined as an artificial device to replace a limb in whole or in part, or to replace an eye, if required because of a change in the patient’s physical condition, as set forth in 42 U.S.C. § 1395x(s)(9).

The insurer, corporation or HMO may require preauthorization to determine medical necessity and the eligibility of benefits for prosthetic devices and components, in the same manner that prior authorization is required for any other covered benefit. The insurer, corporation or HMO may require that prosthetic services be rendered by a provider who contracts with the carrier and that a prosthetic device or component be provided by a vendor designated by that insurer.

The bill proposes coverage that would include the fitting, repair, or replacement of a prosthetic device or components, or both, if the fitting, repair, or replacement is determined to be medically necessary. A fitting, repair, or replacement necessitated by the negligence of proper care and maintenance or by an abusive act committed by the individual having the prosthetic device shall not be covered. Also, coverage shall not be required for a prosthetic device that is designed exclusively for athletic purposes.

The bill prohibits insurers, corporations, or HMOs from imposing any copayment, coinsurance, or deductible amounts, or any policy year or calendar year, lifetime, or other durational limit or maximum for benefits or services that is not equally imposed on terms and services covered under the policy, contract or plan. The bill applies to policies, contracts, or plans delivered, issued for delivery, reissued, or extended on or after January 1, 2008 or at any time thereafter when any term of the policy, contract or plan is changed or premium adjustments are made.

The bill does not apply to short-term travel, accident only, limited or specified disease, or individual conversion policies or contracts, or policies or contracts designed for issuance to persons eligible for Medicare, or similar coverage under government plans.

The Advisory Commission held a public hearing on September 20, 2007 in Richmond to receive public comments on Senate Bill 931. In addition to the patron, Senator Ticer, a representative of Virginia Prosthetics, Roanoke, Virginia and a national spokesperson from the Amputee Coalition of America (ACA) addressed the Advisory Commission. Thirty amputees and family members also commented on Senate Bill 931. Over one hundred concerned citizens attended the public hearing in support of Senate Bill 931. Written comments were received from three orthotic and prosthetic companies and from seventeen concerned citizens. More than 250 signatures were submitted in support of Senate Bill 931. Representatives from the VAHP and the Virginia Chamber of Commerce (VCC) spoke against Senate Bill 931. The VAHP submitted written comments in opposition to the bill.

The Advisory Commission members voted on November 29, 2007 to recommend the enactment of Senate Bill 931 (Yes-6, No-4). The Advisory Commission members discussed the changing needs of health care, the increase of health care costs, maintaining affordable health care and health insurance, and the cross-section of the population impacted by Senate Bill 931. The Advisory Commission concluded that coverage for prosthetic devices and components would significantly impact an individual’s quality of life and improve his or her health. The Advisory Commission believed that the benefits of the proposal compare favorably to the cost of providing the coverage, and the bill should therefore be enacted.