                                 CODE OF VIRGINIA

COVERAGE FOR PROSTHETIC DEVICES AND COMPONENTS (§ 38.2-3418.15:1)

A. 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;Medically necessary prosthetic device&#8221; includes any myoelectric,
biomechanical, or microprocessor-controlled prosthetic device that peer-reviewed
medical literature has determined to be medically appropriate on the basis of
the clinical assessment of the enrollee&#8217;s rehabilitation potential.
			&#8220;Prosthetic device&#8221; means an artificial device to replace, in
whole or in part, a limb.

B. Notwithstanding the provisions of &#xA7; 38.2-3418.15 or 38.2-3419, each
insurer proposing to issue group accident and sickness insurance policies
providing hospital, medical and surgical, or major medical coverage on an
expense-incurred basis, each corporation providing group accident and sickness
subscription contracts, and each health maintenance organization providing a
health care plan for health care services shall provide coverage for medically
necessary prosthetic devices and their repair, fitting, replacement, and
components.

C. The coverage required under subsection B shall be subject to the following:

   1. Coverage for medically necessary prosthetic devices does not include:
   				a. The cost of repair and replacement due to enrollee neglect, misuse, or
   abuse; or
   				b. Prosthetic devices designed primarily for an athletic purpose.

   2. 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.

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

   4. An insurer, corporation, or health maintenance organization shall not
   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 service when such device or service is provided
   by an in-network provider.

   5. 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.

D. The provisions of this section shall apply to any policy, contract, or plan
delivered, issued for delivery, or renewed in the Commonwealth on and after
January 1, 2023, or at any time thereafter when any term of the policy,
contract, or plan is changed or any premium adjustment is made.

E. The provisions of this section shall not apply to (i) short-term travel,
accident-only, or limited or specified disease policies; (ii) policies,
contracts, or plans issued in the individual market or small group markets;
(iii) contracts designed for issuance to persons eligible for coverage under
Title XVIII of the Social Security Act, known as Medicare, Title XIX of the
Social Security Act, known as Medicaid, Title XXI of the Social Security Act, or
any other similar coverage under state or federal governmental plans; or (iv)
short-term nonrenewable policies of not more than six months&#8217; duration.

HISTORY: 2022, cc. 598, 599.