HB2652sam001 96TH GENERAL ASSEMBLY

Sen. Antonio Munoz

Filed: 5/5/2009

09600HB2652sam001 LRB096 10389 RPM 26077 a

AMENDMENT TO HOUSE BILL 2652

AMENDMENT NO. ______. Amend House Bill 2652 by replacing line 5 on page 1 through line 15 on page 5 with the following:

"Section 356z.16 as follows:

(215 ILCS 5/356z.16 new)

Sec. 356z.16. Prosthetic and customized orthotic devices.

(a) For the purposes of this Section:

"Customized orthotic device" means a supportive device for the body or a part of the body, the head, neck, or extremities, and includes the replacement or repair of the device based on the patient's physical condition as medically necessary.

"Licensed provider" means a prosthetist, orthotist, or pedorthist licensed to practice in this State.

"Prosthetic device" means an artificial device to replace, in whole or in part, an arm or leg and includes accessories essential to the effective use of the device and the replacement or repair of the device based on the patient's physical condition as medically necessary.

(b) This amendatory Act of the 96th General Assembly shall provide benefits to any person covered thereunder for expenses incurred in obtaining a prosthetic or custom orthotic device from any Illinois licensed prosthetist, licensed orthotist, or licensed pedorthist as required under the Orthotics, Prosthetics, and Pedorthics Practice Act.

(c) A group or individual policy of accident or health insurance or managed care plan or medical, health, or hospital service corporation contract that provides coverage for prosthetic or custom orthotic care and is amended, delivered, issued, or renewed after the effective date of this amendatory Act of the 96th General Assembly must provide coverage for prosthetic and orthotic devices under terms and conditions that are no less favorable than the terms and conditions applicable to substantially all medical and surgical benefits provided under the plan or coverage.

(d) The policy or plan or contract may require prior authorization for the prosthetic or orthotic devices in the same manner that prior authorization is required for any other covered benefit. Covered benefits are limited to what is determined to be medically necessary.

(e) Repairs and replacements of prosthetic and orthotic devices are also covered, subject to the co-payments and deductibles, unless necessitated by misuse or loss. Such benefits for prosthetic and orthotic devices and components under the plan or coverage may not be subject to separate financial requirements that are applicable only with respect to such benefits; any financial requirements applicable to such benefits may be no more restrictive than the financial requirements applicable to substantially all medical and surgical benefits provided under the plan or coverage.

(f) A policy or plan or contract may require that, if coverage is provided through a managed care plan, the benefits mandated pursuant to this Section shall be covered benefits only if the prosthetic or orthotic devices are provided by a licensed provider employed by a provider service who contracts with or is designated by the carrier, to the extent that the carrier provides in-network and out of network service, the coverage for the prosthetic or orthotic device shall be offered no less extensively.

No insurer corporation or health maintenance organization shall impose upon any person receiving benefits pursuant to this Section, any annual or lifetime dollar maximum on coverage for prosthetic and orthotic devices other than an annual or lifetime dollar maximum that applies in the aggregate to all items and services covered under the policy or plan.

(g) This subsection (g) shall apply to patient access to prosthetic and custom orthotic providers. The policy or plan or contract shall also meet adequacy requirements as established by the Health Care Reimbursement Reform Act of 1985 of the Illinois Insurance Code.".