HB 272: "An Act relating to insurance coverage for prosthetic and orthotic devices; relating to medical assistance for prosthetic and orthotic devices; and providing for an effective date."
00 HOUSE BILL NO. 272 01 "An Act relating to insurance coverage for prosthetic and orthotic devices; relating to 02 medical assistance for prosthetic and orthotic devices; and providing for an effective 03 date." 04 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF ALASKA: 05 * Section 1. AS 21.42 is amended by adding a new section to read: 06 Sec. 21.42.445. Coverage for prosthetic and orthotic devices. (a) A health 07 care insurer that offers, issues for delivery, delivers, or renews in the state a health 08 care insurance plan in the group or individual market shall provide coverage for 09 prosthetic and orthotic devices at a level that is at least equal to the coverage required 10 under 42 U.S.C. 1395k - 1395m. 11 (b) The coverage for prosthetic and orthotic devices required under this 12 section must include all prosthetic or orthotic devices that the covered person's health 13 care provider determines are the most appropriate models to meet the medical needs of 14 the covered person to complete activities of daily living or essential job-related
01 activities, shower or bathe, perform applicable physical activities, including running, 02 biking, swimming, and strength training, and maximize whole-body health and limb 03 function. The coverage must also include all device materials and components and 04 instruction to the covered person on use of the devices. 05 (c) Coverage under this section must include coverage for repair or 06 replacement of a prosthetic or orthotic device as needed. The health care insurer shall 07 provide for the replacement of the device, or the repair or replacement of a part of the 08 device, without regard to continuous use or useful lifetime restrictions, if a health care 09 provider determines that the repair or replacement of the device or a part the device is 10 necessary because a change has occurred in the physiological condition of the covered 11 person or a change has occurred in the condition of the device or in a part of the 12 device that affects its functionality. 13 (d) A health care insurer shall classify the benefits provided under this section 14 as habilitative or rehabilitative benefits to meet state or federal requirements for 15 coverage of essential health benefits. 16 (e) A health care insurer may not deny coverage for a benefit to a covered 17 person with limb loss or absence that would otherwise be covered for a nondisabled 18 covered person seeking medical or surgical intervention to restore or maintain the 19 ability to perform the same physical activity. A health care insurer shall provide 20 replacement coverage when the condition of the prosthetic or orthotic device or a part 21 of the device requires repair and the cost of repair would be more than 60 percent of 22 the cost of replacement of the device or the part of the device needing repair. A health 23 care insurer may require confirmation from a health care provider before providing 24 repair or replacement coverage under this section if the device, or the part of the 25 device needing repair or replacement, is less than three years old. 26 (f) A health care insurer shall ensure at least two distinct providers of 27 prosthetics and orthotics are included within the health care insurer's network in the 28 state. If medically necessary covered prosthetics or orthotics are not available from an 29 in-network provider, the health care insurer shall provide the covered person with a 30 referral to an out-of-network provider and shall fully reimburse the out-of-network 31 provider at a mutually agreed upon rate, less the portion that is the responsibility of the
01 covered person. The copayment of the covered person is determined on an in-network 02 basis. 03 (g) A health care insurer may not require that a person covered under the 04 health care insurer's plan be subject to financial requirements that are applicable only 05 to prosthetic and orthotic coverage. A health care provider may not impose more 06 restrictive cost-sharing requirements for prosthetic or orthotic services than the plan's 07 cost-sharing requirements for inpatient physician and surgical services. 08 (h) A health care insurer shall provide a covered person with a description of 09 the covered person's rights under this section in evidence of coverage and any benefit 10 denial letter. A denial letter must be in writing and explain in detail the reason for the 11 denial, including an explanation as to how the request or claim does not meet the 12 medical necessity standards of the insurer, if applicable. 13 * Sec. 2. AS 47.07.030(b) is amended to read: 14 (b) In addition to the mandatory services specified in (a) of this section and the 15 services provided under (d) of this section, the department may offer only the 16 following optional services: case management services for traumatic or acquired brain 17 injury; case management and nutrition services for pregnant women; personal care 18 services in a recipient's home; emergency hospital services; long-term care 19 noninstitutional services; medical supplies and equipment; advanced practice 20 registered nurse services; clinic services; rehabilitative services for children eligible 21 for services under AS 47.07.063, substance abusers, and emotionally disturbed or 22 chronically mentally ill adults; targeted case management services; inpatient 23 psychiatric facility services for individuals 65 years of age or older and individuals 24 under 21 years of age; psychologists' services; clinical social workers' services; marital 25 and family therapy services; professional counseling services; midwife services; 26 prescribed drugs; physical therapy; occupational therapy; chiropractic services; low- 27 dose mammography screening, as defined in AS 21.42.375(e); hospice care; treatment 28 of speech, hearing, and language disorders; adult dental and dental hygiene services; 29 prosthetic and orthotic devices or replacements as covered in AS 21.42.445(b) and 30 (c); [AND] eyeglasses; optometrists' services; intermediate care facility services, 31 including intermediate care facility services for persons with intellectual and
01 developmental disabilities; skilled nursing facility services for individuals under 21 02 years of age; and reasonable transportation to and from the point of medical care. 03 * Sec. 3. The uncodified law of the State of Alaska is amended by adding a new section to 04 read: 05 REPORTING. (a) Not later than October 1, 2028, a health care insurer subject to 06 AS 21.42.445, added by sec. 1 of this Act, shall submit a report to the director of the division 07 of insurance, Department of Commerce, Community, and Economic Development, on a form 08 determined by the director, that contains the total number of claims and the total amount of 09 claims paid for services required under AS 21.42.445 for the preceding two fiscal years. 10 (b) Before the first day of the First Regular Session of the Thirty-Sixth Alaska State 11 Legislature, the director of the division of insurance, Department of Commerce, Community, 12 and Economic Development, shall prepare a report that contains the information reported 13 under (a) of this section aggregated by fiscal year, and shall deliver the report to the senate 14 secretary and the chief clerk of the house of representatives and notify the legislature that the 15 report is available. 16 (c) Before the first day of the First Regular Session of the Thirty-Sixth Alaska State 17 Legislature, the commissioner of health shall prepare a report aggregated by fiscal year of the 18 total number of claims and the total amount of claims paid for prosthetic and orthotic services 19 provided through medical assistance under AS 47.07.030(b), as amended by sec. 2 of this Act, 20 and shall deliver the report to the senate secretary and the chief clerk of the house of 21 representatives and notify the legislature that the report is available. 22 * Sec. 4. The uncodified law of the State of Alaska is amended by adding a new section to 23 read: 24 APPLICABILITY. AS 21.42.445, added by sec. 1 of this Act, applies to a health care 25 insurance plan or contract issued, delivered, or renewed on or after the effective date of sec. 1 26 of this Act. 27 * Sec. 5. The uncodified law of the State of Alaska is amended by adding a new section to 28 read: 29 MEDICAID STATE PLAN FEDERAL APPROVAL. To the extent necessary to 30 implement this Act, the Department of Health shall amend and submit to the United States 31 Department of Health and Human Services for approval the state plan for medical assistance
01 coverage consistent with AS 47.07.030(b), as amended by sec. 2 of this Act. 02 * Sec. 6. The uncodified law of the State of Alaska is amended by adding a new section to 03 read: 04 CONDITIONAL EFFECT; NOTIFICATION. (a) Section 2 of this Act takes effect 05 only if, on or before January 1, 2027, the United States Department of Health and Human 06 Services 07 (1) approves the amendment to the state plan for medical assistance coverage 08 under AS 47.07.030(b); or 09 (2) determines that approval of the amendment to the state plan for medical 10 assistance coverage under AS 47.07.030(b) is not necessary. 11 (b) The commissioner of health shall notify the revisor of statutes in writing within 30 12 days after the United States Department of Health and Human Services approves the 13 amendment to the state plan or determines that approval is not necessary under this section. 14 * Sec. 7. If sec. 2 of this Act takes effect, it takes effect on the day after the United States 15 Department of Health and Human Services approves the amendment submitted under sec. 6 16 of this Act or determines that approval of the amendment is not necessary.