rehabilitation technology devices; minimum coverage. A. Group health coverage, including any form of self-insurance, offered, issued or renewed under the Health Care Purchasing Act shall provide coverage for prosthetic devices, custom orthotic devices and complex rehabilitation technology devices that is at least equivalent to that coverage currently provided by the federal medicare program and no less favorable than the terms and conditions that the group health plan offers for medical and surgical benefits. Covered benefits shall be provided for more than one prosthetic device or custom orthotic device when medically necessary, but shall include no more than three prosthetic devices or custom orthotic devices per affected limb per covered person; provided that if after three years, a prosthetic device or custom orthotic device is no longer the appropriate device to meet the enrollee's needs for the enrollee's preferred physical activity, coverage and payment for new or replacement devices shall not be limited to three prosthetic or custom orthotic devices per affected limb per covered person. A group health plan shall cover: (1) the most appropriate prosthetic device or custom orthotic device determined to be medically necessary by the enrollee's treating physician and associated medical providers to restore or maintain the ability to complete activities of daily living or essential job-related activities. This coverage shall include all services and supplies necessary for the effective use of a prosthetic device or a custom orthotic device, including: (a) formulation of its design, fabrication, material and component selection, measurements, fittings and static and dynamic alignments; (b) all materials and components necessary to use it; (c) instructing the enrollee in the use of it; and (d) the repair and replacement of it; (2) a prosthetic device or a custom orthotic device determined by the enrollee's provider to be the most appropriate model that meets the medical needs of the enrollee for performing physical activities, including running, biking and swimming, and to maximize the enrollee's upper limb function. This coverage shall include all services and supplies necessary for the effective use of a prosthetic device or a custom orthotic device, including: (a) formulation of its design, fabrication, material and component selection, measurements, fittings and static and dynamic alignments; (b) all materials and components necessary to use it; (c) instructing the enrollee in the use of it; and (d) the repair and replacement of it; and (3) a prosthetic device or custom orthotic device determined by the enrollee's prosthetic or orthotic care provider to be the most appropriate prosthetic device or custom orthotic device that meets the medical needs of the enrollee for purposes of showering or bathing. B. Coverage for complex rehabilitation technology devices shall be based on an enrollee's specific medical, physical, functional and environmental needs and capacities to engage in normal life activities and shall allow an enrollee to obtain more than one complex rehabilitation technology device, but no more than two complex rehabilitation technology devices per covered person; provided that if after three years, a complex rehabilitation technology device is no longer the appropriate device to meet the enrollee's needs for the enrollee's preferred physical activity, coverage and payment for new or replacement devices shall not be limited to two complex rehabilitation technology devices per covered person. A group health plan shall cover: (1) complex rehabilitation technology devices for daily use that meet the enrollee's mobility and positioning needs; (2) complex rehabilitation technology devices to enable the enrollee to participate in physical activities necessary to achieve or maintain health goals; and (3) all services and supplies necessary for the effective use of a complex rehabilitation technology device, including: (a) configuring, fitting, programming, adjusting or adapting the particular device for use by a person, including the formulation of the device's design, fabrication, material and component selection and measurements; (b) all materials and components necessary to use the device; (c) instructing the enrollee in the use of the device; and (d) the repair and replacement of the device. C. A group health plan's reimbursement rate for prosthetic devices, custom orthotic devices or complex rehabilitation technology devices shall be at least equivalent to that currently provided by the federal medicare program and no more restrictive than other coverage under the group health plan. D. Prosthetic device, custom orthotic device or complex rehabilitation technology device coverage shall be comparable to coverage for other medical and surgical benefits under the group health plan, including restorative internal devices such as internal prosthetic devices, and shall not be subject to spending limits or lifetime restrictions. E. Prosthetic device, custom orthotic device or complex rehabilitation technology device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage. A group health plan may impose cost sharing on prosthetic devices, custom orthotic devices or complex rehabilitation technology devices; provided that any cost-sharing requirements shall not be more restrictive than the cost-sharing requirements applicable to the plan's medical and surgical benefits, including those for internal devices. F. A group health plan may limit the coverage for, or alter the cost-sharing requirements for, out-of-network coverage of prosthetic devices, custom orthotic devices or complex rehabilitation technology devices; provided that the restrictions and cost-sharing requirements applicable to prosthetic devices, custom orthotic devices or complex rehabilitation technology devices shall not be more restrictive than the restrictions and requirements applicable to the out-of-network coverage for a group health plan's medical and surgical coverage. G. In the event that medically necessary covered prosthetic devices, custom orthotic devices or complex rehabilitation technology devices are not available from an in- network provider, the insurer shall provide processes to refer a member to an out-of- network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less member cost sharing determined on an in-network basis. H. A group health plan shall not impose any annual or lifetime dollar maximum on coverage for prosthetic devices, custom orthotic devices or complex rehabilitation technology devices other than an annual or lifetime dollar maximum that applies in the aggregate to all terms and services covered under the group health plan. I. If coverage is provided through a managed care plan, an enrollee shall have access to medically necessary clinical care and to prosthetic devices, custom orthotic devices or complex rehabilitation technology devices and technology from not less than two distinct prosthetic device, custom orthotic device or complex rehabilitation technology device providers in the managed care plan's provider network located in the state. J. Coverage for prosthetic devices, custom orthotic devices or complex rehabilitation technology devices shall be considered habilitative or rehabilitative benefits for purposes of any state or federal requirement for coverage of essential health benefits, including habilitative and rehabilitative benefits. K. If coverage for prosthetic devices, custom orthotic devices or complex rehabilitation technology devices is provided, payment shall be made for the replacement of a prosthetic device, a custom orthotic device or a complex rehabilitation technology device or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary because of any of the following: (1) a change in the physiological condition of the patient; (2) an irreparable change in the condition of the device or in a part of the device; or (3) the condition of the device or the part of the device requires repairs, and the cost of such repairs would be more than sixty percent of the cost of a replacement device or of the part being replaced. L. A complex rehabilitation technology device that is a manual or power wheelchair shall only be covered pursuant to this section if the: (1) enrollee has undergone a complex rehabilitation technology device evaluation conducted by a licensed physical therapist or occupational therapist who has no financial relationship with the supplier of the complex rehabilitation technology device; and (2) complex rehabilitation technology device is provided by a complex rehabilitation technology device supplier that: (a) employs at least one assistive technology professional certified by the rehabilitation engineering and assistive technology society of North America who specialized in seating, positioning and mobility and has direct, in-person involvement in the wheelchair selection for the enrollee; and (b) makes at least one qualified complex rehabilitation technology device service technician available in each service area served by the supplier to service and repair devices that are furnished by the supplier. M. Confirmation from a prescribing health care provider may be required if the prosthetic device, custom orthotic device or complex rehabilitation technology device or part being replaced is less than three years old. N. A group health plan subject to the Health Care Purchasing Act shall not discriminate against individuals based on disability, including limb loss, absence or malformation. O. As used in this section, "complex rehabilitation technology device" means a subset of durable medical equipment that: (1) consists of complex rehabilitation manual and power wheelchairs and mobility devices, including specialized seating and positioning items, options and accessories; (2) is designed, manufactured, configured, adjusted or modified for a specific person to meet that person's unique medical, physical, functional and environmental needs and capacities; (3) is generally not useful to a person in the absence of a disability, illness, injury or other medical condition; and (4) requires specialized services to ensure appropriate use of the item, including: (a) an evaluation of the features and functions necessary to assist the person who will use the device; or (b) configuring, fitting, programming, adjusting or adapting the particular device for use by a person. History: Laws 2023, ch. 196, § 1; 2026, ch. 41, § 1.
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