2012 Indiana Code
TITLE 27. INSURANCE
ARTICLE 8. LIFE, ACCIDENT, AND HEALTH
CHAPTER 24.2. COVERAGE FOR PROSTHETIC DEVICES

IC 27-8-24.2
Chapter 24.2. Coverage for Prosthetic Devices

IC 27-8-24.2-0.1
Application of chapter
Sec. 0.1. The addition of this chapter by P.L.109-2008 applies to a policy of accident and sickness insurance that is issued, delivered, amended, or renewed after June 30, 2008.
As added by P.L.220-2011, SEC.450.

IC 27-8-24.2-1
"Insured"
Sec. 1. As used in this chapter, "insured" means an individual who is entitled to coverage under a policy of accident and sickness insurance.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-2
"Orthotic device"
Sec. 2. As used in this chapter, "orthotic device" means a medically necessary custom fabricated brace or support that is designed as a component of a prosthetic device.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-3
"Policy of accident and sickness insurance"
Sec. 3. (a) As used in this chapter, "policy of accident and sickness insurance" has the meaning set forth in IC 27-8-5-1.
(b) The term does not include the following:
(1) Accident only, credit, dental, vision, Medicare, Medicare supplement, long term care, or disability income insurance.
(2) Coverage issued as a supplement to liability insurance.
(3) Automobile medical payment insurance.
(4) A specified disease policy.
(5) A limited benefit health insurance policy.
(6) A short term insurance plan that:
(A) may not be renewed; and
(B) has a duration of not more than six (6) months.
(7) A policy that provides a stipulated daily, weekly, or monthly payment to an insured during hospital confinement, without regard to the actual expense of the confinement.
(8) Worker's compensation or similar insurance.
(9) A student health insurance policy.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-4
"Prosthetic device"
Sec. 4. As used in this chapter, "prosthetic device" means an artificial leg or arm.
As added by P.L.109-2008, SEC.2.
IC 27-8-24.2-5
Coverage required
Sec. 5. A policy of accident and sickness insurance must provide coverage for orthotic devices and prosthetic devices, including repairs or replacements, that:
(1) are provided or performed by a person that is:
(A) accredited as required under 42 U.S.C. 1395m(a)(20); or
(B) a qualified practitioner (as defined in 42 U.S.C. 1395m(h)(1)(F)(iii));
(2) are determined by the insured's physician to be medically necessary to restore or maintain the insured's ability to perform activities of daily living or essential job related activities; and
(3) are not solely for comfort or convenience.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-6
Coverage and reimbursement
Sec. 6. The:
(1) coverage required under section 5 of this chapter must be equal to the coverage that is provided for the same device, repair, or replacement under the federal Medicare program (42 U.S.C. 1395 et seq.); and
(2) reimbursement under the coverage required under section 5 of this chapter must be equal to the reimbursement that is provided for the same device, repair, or replacement under the federal Medicare reimbursement schedule, unless a different reimbursement rate is negotiated.
This section does not require a deductible under a policy of accident and sickness insurance to be equal to a deductible under the federal Medicare program.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-7
Comparison to other benefits
Sec. 7. Except as provided in sections 8 and 9 of this chapter, the coverage required under section 5 of this chapter:
(1) may be subject to; and
(2) may not be more restrictive than;
the provisions that apply to other benefits under the policy of accident and sickness insurance.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-8
Continued medical necessity review
Sec. 8. The coverage required under section 5 of this chapter may be subject to utilization review, including periodic review, of the continued medical necessity of the benefit.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-9 Lifetime maximum coverage limitation
Sec. 9. Any lifetime maximum coverage limitation that applies to prosthetic devices and orthotic devices:
(1) must not be included in; and
(2) must be equal to;
the lifetime maximum coverage limitation that applies to all other items and services generally under the policy of accident and sickness insurance.
As added by P.L.109-2008, SEC.2.

IC 27-8-24.2-10
Deductible, copayment, or coinsurance requirements
Sec. 10. For purposes of this section, "items and services" does not include preventive services for which coverage is provided under a high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26 U.S.C. 223(c)(2)). The coverage required under section 5 of this chapter may not be subject to a deductible, copayment, or coinsurance provision that is less favorable to an insured than the deductible, copayment, or coinsurance provisions that apply to other items and services generally under the policy of accident and sickness insurance.
As added by P.L.109-2008, SEC.2.