                                 CODE OF VIRGINIA

COVERAGE FOR PROSTHETIC DEVICES AND COMPONENTS (§ 38.2-3418.15)

A. Notwithstanding the provisions of § 38.2-3419, each insurer proposing to
issue individual or group accident and sickness insurance policies providing
hospital, medical and surgical, or major medical coverage on an expense-incurred
basis; each corporation providing individual or group accident and sickness
subscription contracts; and each health maintenance organization providing a
health care plan for health care services shall offer and make available
coverage for medically necessary prosthetic devices, their repair, fitting,
replacement, and components, as follows:

   1. As used in this section:
   				&#8220;Component&#8221; means the materials and equipment needed to ensure
   the comfort and functioning of a prosthetic device.
   				&#8220;Limb&#8221; means an arm, a hand, a leg, a foot, or any portion of
   an arm, a hand, a leg, or a foot.
   				&#8220;Prosthetic device&#8221; means an artificial device to replace, in
   whole or in part, a limb.

   2. Prosthetic device coverage does not include repair and replacement due to
   enrollee neglect, misuse, or abuse. Coverage also does not include prosthetic
   devices designed primarily for an athletic purpose.

   3. An insurer 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 items and services covered under
   the policy. The coverage may be made subject to, and no more restrictive than,
   the provisions of a health insurance policy that apply to other benefits under
   the policy.

   4. An insurer shall not apply amounts paid for prosthetic devices to any
   annual or lifetime dollar maximum applicable to other durable medical
   equipment covered under the policy other than an annual or lifetime dollar
   maximum that applies in the aggregate to all items and services covered under
   the policy.

   5. No insurer, corporation, or health maintenance organization shall impose
   upon any person receiving benefits pursuant to this section any coinsurance in
   excess of 30 percent of the carrier&#8217;s allowable charge for such
   prosthetic device or services when such device or service is provided by an
   in-network provider.

   6. An insurer, corporation, or health maintenance organization 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.

B. The requirements of this section shall apply to all insurance policies,
contracts, and plans delivered, issued for delivery, reissued, or extended in
the Commonwealth on and after January 1, 2010, or at any time thereafter when
any term of the policy, contract, or plan is changed or any premium adjustment
is made.

C. This section shall not apply to short-term travel, accident-only, or limited
or specified disease policies or contracts, nor to policies or contracts
designed for issuance to persons eligible for coverage under Title XVIII of the
Social Security Act, known as Medicare, or any other similar coverage under
state or federal governmental plans.

HISTORY: 2009, c. 839; 2014, c. 814.