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Being Proposed by the Missouri Coalition for People with Limb Loss

MISSOURI PROSTHETIC PARITY BILL

HB – Require Coverage under Health Insurance Policies for Prosthetic Devices

This bill requires private health insurance companies to provide a minimum of Medicare-
level coverage of medically necessary prosthetic devices.

(1) All individual and group health insurance plans providing coverage for hospital,
medical or surgical expenses and is delivered, issued, executed or renewed in
Missouri shall include coverage for benefits for prosthetic devices that, at a
minimum, equals the coverage provided for under the federal Medicare program
pursuant to 42 U.S.C. secs. 1395k, 1395l, 1395m and 42 CFR 414.202, 414.210,
414.228, and 414.100. The coverage required by this subsection includes all
services and supplies medically necessary for the effective use of a prosthetic
device, including formulating its design, fabrication, material and component
selection, measurements, fittings, static and dynamic alignments, and instructing
the patient in the use of the device.

(2) As used in this section, “Prosthetic device” means an artificial limb, device or
appliance designed to replace in whole or in part arms, legs, or eyes, as set forth
at 42 U.S.C. sec. 1395x(s)(9).

(3) A health insurance provider may require prior authorization for prosthetic devices
in the same manner that prior authorization is required for any other covered
benefit.

(4) A health benefit plan may impose copayment and/or coinsurance amounts on
prosthetic devices, not to exceed the copayment and/or coinsurance amounts
imposed under Part B of the Medicare fee-for-service program. A health benefit
plan shall reimburse for such prosthetics at no less than the fee schedule amount
for such prosthetics under the federal Medicare reimbursement schedule.

(5) Covered benefits are limited to the most appropriate model that adequately meets
the medical needs of the insured to perform activities of daily living and essential
job-related activities, as determined by the insured’s treating physician.

(6) The coverage required by this section shall include any repair or replacement of a
prosthetic device that is determined medically necessary to restore or maintain
the ability to complete activities of daily living or essential job-related activities.

(7) The health benefit plan shall not impose any annual or lifetime dollar maximum
on coverage for prosthetic devices other than an annual or lifetime dollar
maximum that applies in the aggregate to all terms and services covered under
the plan.