§ 4088f. Prosthetic parity

(a) As used in this section:

(1) "Health insurance plan" means any health insurance policy or health benefit plan offered by a health insurer, as defined in 18 V.S.A. § 9402, as well as Medicaid and any other public health care assistance program offered or administered by the State or by any subdivision or instrumentality of the State. The term shall not include policies or plans providing coverage for a specific disease or other limited benefit coverage.

(2) "Prosthetic device" means an artificial limb device to replace, in whole or in part, an arm or a leg.

(b) A health insurance plan shall provide coverage for prosthetic devices in all health plans at least equivalent to that provided by the federal Medicare program. Coverage may be limited to the prosthetic device that is the most appropriate model that is medically necessary to meet the patient's medical needs. Any dispute between the insured and the carrier concerning coverage and the application of this section shall be subject to independent external review under section 4089f of this title.

(c) A health insurance plan may require prior authorization for prosthetic devices in the same manner and to the same extent as prior authorization is required for any other covered benefit.

(d) A health insurance plan shall provide coverage under this section for the medically necessary repair or replacement of a prosthetic device.

(e) A health insurance plan shall not impose any annual or lifetime dollar maximum on coverage for prosthetics that is less than the annual or lifetime dollar maximum that applies generally to all terms and services covered under the plan.

(f) The coverage required may not be subject to a deductible, co-payment, or coinsurance provision that is less favorable to a covered individual than the deductible, co-payment, or coinsurance provisions that apply generally to other non-primary care items and services under the health plan. (Added 2007, No. 103 (Adj. Sess.), § 1, eff. Oct. 1, 2008; amended 2015, No. 97 (Adj. Sess.), § 16.)