Offer of Coverage for Prosthetic Devices and Services

PURPOSE: This rule defines “prosthetic devices and services” for purposes of the mandated offer of coverage required under section 376.1232, RSMo, and clarifies the related obligations for health carriers and health benefit plans. (1) As used in this rule and section 376.1232, RSMo, the term “prosthetic devices” shall have the same meaning as described in the federal Medicare program definitions under 42 U.S.C. section 1395x(s)(8) and (9). (2) As used in this rule and section 376.1232, RSMo, the term “services” means— (A) Design, fabrication, and customization of the prosthetic device; (B) Required visits or fittings with the prosthetics device supplier prior to receiving the prosthetic device; (C) Proper fitting of the prosthetic device; (D) Visits with qualified medical professionals, where such visits are necessary to train the recipient of the prosthetic device in the use of the prosthetic device, and visits necessary to train family members or caregivers, if applicable; (E) Post-fitting and adjustment visits after receiving the prosthetic device, no less than annually or more frequently if necessary; (F) Necessary modifications after receiving the prosthetic device because of physical changes or excessive stump AND INSURANCE shrinkage; (G) Repair or replacement due to defects in materials and workmanship, to the extent that such is not already covered by a warranty offered by the manufacturer or supplier of the prosthetic device; (H) Repair or replacement due to structural integrity issues; and/or (I) Periodic evaluation and patient care in order to assess the prosthetic device’s effect on the patient’s tissues and to assure continued proper fit and function. (3) A health carrier may offer coverage more generous than the coverage described in this rule or in section 376.1232, RSMo. (4) If the offer of coverage described in this rule and in section 376.1232, RSMo, is not accepted by the purchaser of the health benefit plan, nothing in this rule or in section 376.1232, RSMo, shall be construed to prevent the health carrier from offering alternative coverage for prosthetic devices and services or from using alternative definitions of these terms. AUTHORITY: sections 374.045 and 376.1232, RSMo Supp. 2010.* Original rule filed Sept. 15, 2010, effective April 30, 2011. *Original authority: 374.045, RSMo 1967, amended 1993, 1995, 2008 and 376.1232, RSMo 2009.