Wisconsin Society of Orthotists, Prosthetists & Pedorthists
Wisconsin Model Parity Bill
(WSOPP revision 1/22/08)
(Milwaukee committee; ACA; Parity Committee reviewed)
All individual and group health insurance policies providing covered services for hospital, medical or surgical expenses shall also provide coverage for prosthetic and orthotic devices that-are otherwise provided for and billed under the Federal Health Care Financing Administration (HCFA) procedure coding system as directed by the United States Department of Health and Human Services.
(a) 'Orthotic device' is defined as a rigid or semi rigid device supporting a weak or deformed body part which may include, but is not limited to the leg, foot, arm, hand, torso, neck or head, or to restrain, limit or enhance motion in a diseased or injured body part which may include, but is not limited to the leg, foot, arm, hand, torso, neck or head.
(b) 'Prosthetic device' is defined as a replacement for or an external body part, and which is designed to replace the absent body part in whole or in part.
The coverage required includes all orthotic and prosthetic services and supplies deemed to be medically necessary by the prescribing physician. This includes the design, fabrication, material and component selection, measurements, fittings, static and dynamic alignment, device maintenance, and instructing the patient in the use and care of the device.
The covered services may be made subject to, but no more restrictive than, the provisions of a health insurance policy that apply to other benefits under the policy.
The covered services required should include any repair or replacement of a prosthetic or orthotic device that is determined to be medically necessary by the prescribing physician.
A health benefit plan shall not impose any maximum annual or lifetime dollar limits on coverage for prosthetics and orthotics, other than an annual or lifetime dollar maximum that applies in the aggregate to all terms and services covered under the policy. Any copayment, coinsurance, deductible, and maximum out-of-pocket expenses applied to the benefit for orthotic or prosthetic services shall be no more than that which applies to other medical services covered under the plan.
If coverage is provided through a managed health care plan, the insured shall have local access to medically necessary prosthetic and orthotic services from not less than two distinct Wisconsin providers of prosthetic or orthotic devices within the plan's provider network, or access to an out of network provider at in-network benefits.
