Nonprofit Medical Service Corporations
§ 27-20-52 Reimbursement for orthotics and
(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
(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
(i) based in the state of Rhode Island; or
(ii) provides coverage for citizens for the state of Rhode
(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.)