§27-20-52  Reimbursement for orthotics and prosthetic services. –

Link to law: http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-20/27-20-52.HTM
Published: 2015

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TITLE 27

Insurance

CHAPTER 27-20

Nonprofit Medical Service Corporations

SECTION 27-20-52



   § 27-20-52  Reimbursement for orthotics and

prosthetic services. –

(a) As used in this section:



   (1) "Federal reimbursement rates" means the current listed

fee schedule from the Centers for Medicare and Medicaid Services, listing the

current Healthcare Common Procedure Coding system (HCPCS) and the corresponding

reimbursement rates.



   (2) "Orthosis" means a custom fabricated brace or support

that is designed based on medical necessity. Orthosis does not include

prefabricated or direct-formed orthotic devices, as defined in this section, or

any of the following assistive technology devices: commercially available knee

orthoses used following injury or surgery; spastic muscle-tone inhibiting

orthoses; upper extremity adaptive equipment; finger splints; hand splints;

wrist gauntlets; face masks used following burns; wheelchair seating that is an

integral part of the wheelchair and not worn by the patient independent of the

wheelchair; fabric or elastic supports; corsets; low-temperature formed plastic

splints; trusses; elastic hose; canes; crutches; cervical collars; dental

appliances; and other similar devices as determined by the director of the

department 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 evaluating

measuring, designing, fabricating, assembling, fitting, adjusting or servicing,

as well as providing the initial training necessary to accomplish the fitting

of, an orthosis for the support, correction, or alleviation of neuromuscular or

musculoskeletal dysfunction, disease, injury or deformity. The practice of

orthotics encompasses evaluation, treatment, and consultation; with basic

observational gait and postural analysis, orthotists assess and design orthoses

to maximize function and provide not only the support but the alignment

necessary to either prevent or correct a deformity or to improve the safety and

efficiency of mobility or locomotion or both. Orthotic practice includes

providing continuing patient care in order to assess its effect on the

patient's tissues and to assure proper fit and function of the orthotic device

by periodic evaluation.



   (4) "Prosthesis" means an artificial limb that is alignable

or, in lower-extremity applications capable of weight bearing. Prosthesis means

an artificial medical device that is not surgically implanted and that is used

to replace a missing limb, appendage, or other external human body part

including an artificial limb, hand, or foot. The term does not include

artificial eyes, ears, noses, dental appliances, osotmy products, or devices

such as eyelashes or wigs.



   (5) "Prosthetics" means the science and practice of

evaluation, measuring, designing, fabricating, assembling, fitting, aligning,

adjusting or servicing, as well as providing the initial training necessary to

accomplish the fitting of, a prosthesis through the replacement of external

parts of a human body lost due to amputation or congenital deformities or

absences. The practice of prosthetics also includes the generation of an image,

form, or mold that replicates the patient's body or body segment and that

requires rectification of dimensions, contours and volumes for use in the

design and fabrication of a socket to accept a residual anatomic limb to, in

turn, create an artificial appendage that is designed either to support body

weight or to improve or restore function or cosmesis, or both. Involved in the

practice of prosthetics is observational gait analysis and clinical assessment

of the requirements necessary to refine and mechanically fix the relative

position of various parts of the prosthesis to maximize function, stability,

and safety of the patient. The practice of prosthetics includes providing and

continuing patient care in order to assess the prosthetic device's effect on

the patient's tissues and to assure proper fit and function of the prosthetic

device by periodic evaluation.



   (6) "Private insurance company" means any insurance company,

or management company hired by an insurance company, who is any of the

following:



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



   (ii) provides coverage for citizens for the state of Rhode

Island; or



   (iii) allows subscribing patients to seek prosthetic or

orthotic services in the state of Rhode Island.



   (b) Every individual or group health insurance contract, plan

or policy delivered, issued for delivery or renewed in this state on or after

January 1, 2006, which provides medical coverage that includes coverage for

physician services in a physician's office and every policy, which provides

major medical or similar comprehensive type coverage shall provide coverage for

benefits for orthotic and prosthetic devices that equal those benefits provided

for under federal laws for health insurance for the aged and disabled pursuant

to 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 require

prior authorization for orthotic and prosthetic devices in the same manner that

prior authorization is required for any other covered benefit.



   (d) Covered benefits for orthotic or prosthetic devices shall

be limited to the most appropriate model that adequately meets the medical

needs of the patient as determined by the insured's treating physician.



   (e) The repair and replacement of orthotic or prosthetic

devices also shall be covered subject to co-payments and deductibles, unless

necessitated by misuse or loss.



   (f) An insurer may require, if coverage is provided through a

managed care plan, that benefits mandated pursuant to this section be covered

benefits only if the orthotic or prosthetic devices are provided by a vendor

and orthotic or prosthetic services are rendered by a provider who is licensed

by the state of Rhode Island to provide orthotics and prosthetics.



History of Section.

(P.L. 2006 ch. 210, § 3; P.L. 2006, ch. 380, § 3.)