S3919

An Act concerning health benefits coverage and prosthetic appliances and amending P.L.2007, c.345.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. Section 1 of P.L.2007, c.345 (C.17:48-6ff) is amended to read as follows:

1. a. Every hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

(2) an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, if the covered person’s physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports.

As used in this section, "orthotic appliance," "prosthetic appliance," "licensed orthotist" and "licensed prosthetist" have the meaning assigned to them in section 3 of P.L.1991, c.512 (C.45:12B-3) and "certified pedorthist" has the meaning assigned to it in subsection j. of section 18 of P.L.1991, c.512 (C.45:12B-18).

b. On and after the effective date of this act, a hospital service corporation contract shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the contract.

d. The provisions of this section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.

(cf: P.L.2007, c.345, s.1)

2. Section 2 of P.L.2007, c.345 (C.17:48A-7cc) is amended to read as follows:

2. a. Every medical service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, a medical service corporation contract shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the contract.

d. The provisions of this section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.

(cf: P.L.2007, c.345, s.2)

3. Section 3 of P.L.2007, c.345 (C.17:48E-35.30) is amended to read as follows:

3. a. Every health service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, a health service corporation contract shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the contract.

d. The provisions of this section shall apply to all health service corporation contracts in which the health service corporation has reserved the right to change the premium.

(cf: P.L.2007, c.345, s.3)

4. Section 4 of P.L.2007, c.345 (C.17B:26-2.1z) is amended to read as follows:

4. a. Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, an individual health insurance policy shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all individual health insurance policies in which the insurer has reserved the right
to change the premium.

(cf: P.L.2007, c.345, s.4)

5. Section 5 of P.L.2007, c.345 (C.17B:27-46.1ff) is amended to read as follows:

5. a. Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, a group health insurance policy shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the policy.

d. The provisions of this section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.

(cf: P.L.2007, c.345, s.5)

6. Section 6 of P.L.2007, c.345 (C.17B:27A-7.13) is amended to read as follows:

6. a. Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, an individual health benefits plan shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.

(cf: P.L.2007, c.345, s.6)

7. Section 7 of P.L.2007, c.345 (C.17B:27A-19.17) is amended to read as follows:

7. a. Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance on or after the effective date of this act, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, a small employer health benefits plan shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the health benefits plan.

d. The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.

(cf: P.L.2007, c.345, s.7)

8. Section 8 of P.L.2007, c.345 (C.26:2J-4.31) is amended to read as follows:

8. a. A certificate of authority to establish and operate a health maintenance organization in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Health and Senior Services on or after the effective date of this act unless the health maintenance organization provides health care services for any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, a health maintenance organization shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the enrollee agreement.

d. The provisions of this section shall apply to all enrollee agreements in which the health maintenance organization has reserved the right to change the schedule of charges.

(cf: P.L.2012, c.17, s.276)

9. Section 9 of P.L.2007, c.345 (C.52:14-17.29m) is amended to read as follows:

9. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits, shall provide benefits to any person covered thereunder for expenses incurred in obtaining:

(1) an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician; and

b. On and after the effective date of this act, a contract purchased by the commission shall reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.

c. The benefits shall be provided to the same extent as for any other medical condition under the contract.

(cf: P.L.2007, c.345, s.9)

10. This act shall take effect on the 90th day after enactment, and shall apply to policies or contracts issued or renewed on or after the effective date.

STATEMENT

This bill requires health benefits coverage for an additional prosthetic appliance under certain circumstances.

The bill requires health benefits coverage for an additional orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, if the covered person’s physician determines that the additional appliance is necessary to enable the covered person to engage in physical and recreational activities, including running, bicycling, swimming, climbing, skiing, snowboarding, and team and individual sports. The reimbursement for the additional orthotic or prosthetic appliance is at the same rate as reimbursement for the appliances under the federal Medicare reimbursement schedule.

Current law requires health benefits coverage for expenses incurred in obtaining an orthotic or prosthetic appliance from any licensed orthotist or prosthetist, or any certified pedorthist, as determined medically necessary by the covered person's physician, but does not require coverage of an additional appliance for physical or recreational activities.

The bill would apply to hospital, medical, and health service corporations; commercial individual, small employer, and larger group insurers; health maintenance organizations; and the State Health Benefits Program and the School Employees’ Health Benefits Program.