{"data":{"id":"us-ky/krs-304.17a-128","jurisdiction":"us-ky","citation":"KRS 304.17A-128","heading":"Coverage for prostheses and orthoses -- Utilization review decision --","body":"Denial letter -- Network adequacy -- Reports.  (Effective January 1, 2027)\n(1) As used in this section, \"health benefit plan\" has the same meaning as in KRS\n304.17A-005, except for purposes of this section, the term includes student health\ninsurance offered by a Kentucky -licensed insurer under written contract with a\nuniversity or college whose students it proposes to insure.\n(2) All health benefit plans shall provide coverage for prostheses and orthoses.\n(3) The coverage required under this section:\n(a) Shall, at a minimum, be equivalent to the coverage of, and payment for,\nprostheses and orthoses provided for the aged and disabled under the\nfollowing, as amended:\n1. 42 U.S.C. sec. 1395k;\n2. 42 U.S.C. sec. 1395l;\n3. 42 U.S.C. sec. 1395m;\n4. 42 C.F.R. sec. 410.100;\n5. 42 C.F.R. sec. 414.202;\n6. 42 C.F.R. sec. 414.210; and\n7. 42 C.F.R. sec. 414.228;\n(b) To the extent not covered under paragraph (a) of this subsection, shall\ninclude:\n1. Subject to paragraph (e) of this subsection, coverage for any one (1) or\nmore prostheses and orthoses prescribed by an insured's health care\nprovider and determined by a li censed prosthetist or orthotist to be the\nmost appropriate model or models that adequately meet the medical\nneeds of the insured for purposes of each of the following:\na. Completing activities of daily living;\nb. Completing essential job-related activities;\nc. Performing physical activities, including but not limited to\nrunning, biking, swimming, and strength training;\nd. Maximizing the insured's whole -body health, including lower and\nupper limb function; or\ne. Showering and bathing;\n2. For any prosthesis or orthosis covered under this section, coverage for:\na. All materials and components necessary to use the prosthesis or\northosis;\nb. Instruction to the insured on using the prosthesis or orthosis; and\nc. The repair of the prosthesis or orthosis or any of its parts; and\n3. a. Subject to subdivision b. of this subparagraph, coverage for the\nreplacement of a prosthesis or orthosis, or any of its parts, covered\nunder this section without regard to continuous use or useful\nlifetime restrictions, if the prescribi ng health care professional\ndetermines that a replacement or part is necessary because of any\nof the following:\ni. A change in the physiological condition of the patient;\nii. An irreparable change in the condition of the prosthesis or\northosis or any of its parts; or\niii. The cost to repair the device or part would be more than\nsixty percent (60%) of the cost of a replacement device or of\nthe part being replaced.\nb. If a prosthesis or orthosis that is less than three (3) years old is\nbeing replaced, the insurer offering or providing the health benefit\nplan may require confirmation of the need for a replacement from\nthe ordering health care professional;\n(c) Shall not be subject to cost-sharing requirements that are applicable only\nwith respect to the coverage required under this section;\n(d) May be subject to cost -sharing requirements if the requirements are not\nmore restrictive than the cost -sharing requirements for inpatient\nphysician and surgical services;\n(e) May be subject to a limit of three (3) prosthe ses and orthoses per\naffected limb within a three (3) year period; and\n(f) Shall be considered habilitative or rehabilitative services and devices for\npurposes of any federal requirements to provide coverage for essential\nhealth benefits.\n(4) (a) With respect to the coverage required under this section, a utilization review\ndecision rendered by an insurer or its private review agent shall:\n1. Be made in a nondiscriminatory manner; and\n2. Not deny coverage solely on the basis of the insured's actual or\nperceived disability.\n(b) An insurer or its private review agent shall provide a description of the\ninsured's rights under paragraph (a) of this subsection in:\n1. The health benefit plan's evidence of coverage; and\n2. Any denial letter relating to the coverage required under this section.\n(5) If an insurer or its private review agent denies the coverage required under this\nsection based on medical necessity, the insurer or agent shall provide a denial letter\nto the insured and the provider that:\n(a) Is in writing;\n(b) Explains why the claim does not meet medical necessity standards; and\n(c) Complies with any other applicable state and federal laws.\n(6) (a) An insurer or administrator that utili zes a network to provide prostheses and\northoses under a health benefit plan shall ensure that the network is\nreasonably adequate and accessible with respect to the provision of prostheses\nand orthoses required to be covered under this section.\n(b) A reaso nably adequate network, with respect to the provision of prostheses\nand orthoses that are required to be covered under this section, shall, at a\nminimum, offer an adequate number of accessible prosthetists or orthotists in\naccordance with the requirements set forth for managed care plans in KRS\n304.17A-515.\n(7) (a) By June 1 of each year, each insurer that offers or provides a health benefit\nplan shall submit a report to the commissioner detailing the insurer's\nexperience with providing the coverage required under this section.\n(b) The report required under paragraph (a) of this subsection shall:\n1. Be in a form prescribed by the commissioner in an administrative\nregulation promulgated in accordance with KRS Chapter 13A; and\n2. With respect to the coverage r equired under this section, include the\nfollowing for the preceding plan year:\na. The number of claims received; and\nb. The number of claims paid.\n(c) By October 1 of each year, the commissioner shall submit a report to the\nLegislative Research Commission, for referral to the Interim Joint Committee\non Banking and Insurance, that provides the aggregated data of the reports\nsubmitted under paragraph (b) of this subsection by plan year.","path":[],"source_url":"https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=58243","current_through":"Includes enactments through the 2026 Regular Session","vintage":"09/05/2026","retrieved_at":"2026-09-05T20:57:46Z","sha256":"09fe160c937c231a5f572820ee4e2bd8cb369c91a812e273fc3c2efa0b980882","source_id":"us-ky","stale":false,"prev":"us-ky/krs-304.17a-120","next":"us-ky/krs-304.17a-129"},"notice":"GroundRules: Original legal text. Not legal advice."}