Lymph Activist's

GENERAL ASSEMBLY OF NORTH CAROLINA

Session 2009
Legislative Actuarial Note

HEALTH BENEFITS

House Bill 535 (First Edition) 1

BILL NUMBER: House Bill 535 (First Edition)
SHORT TITLE: Health Insurance Coverage/Lymphedema.
SPONSOR(S): Representatives Insko, England, Cotham, and Stewart
SYSTEM OR PROGRAM AFFECTED: State Health Plan for Teachers and State Employees (Plan).

BILL SUMMARY:

March 11, 2009

H 535. HEALTH INSURANCE COVERAGE/LYMPHEDEMA.

Filed 3/11/09. TO REQUIRE HEALTH INSURERS, INCLUDING THE STATE HEALTH PLAN, TO PROVIDE COVERAGE FOR THE DIAGNOSIS AND TREATMENT OF LYMPHEDEMA.

Enacts new GS 58-3-280 to establish that every health benefit plan, as defined in GS 58-3-167, must provide coverage for the diagnosis, evaluation, and treatment of lymphedema. Requires benefits for equipment, supplies, complex decongestive therapy, gradient compression garments, and outpatient self-management training and education, if the treatment is determined to be medically necessary and is provided by a health care professional approved and licensed or certified by the state to provide diagnosis, evaluation, and treatment for lymphedema. Provides that the same deductibles, coinsurance, and other limitations as apply to similar services must apply to the coverage of lymphedema. Specifies that gradient compression garments (1) require a prescription, (2) are custom-fit for the covered individual, and (3) do not include disposable medical supplies such as over-the-counter compression or elastic knee-high or other stocking products.

Amends GS 90-270.26 and GS 90-270.69 to add to the powers and duties of the North Carolina Board of Physical Therapy Examiners and the North Carolina Board of Occupational Therapy, respectively, that mechanisms be established for assessing the training and competence of practitioners in performing lymphedema treatment.

Effective for all health benefit plans delivered, issued for delivery, or renewed on and after January 1, 2010
Source: Bill Digest H.B. 535 (03/11/0200).

EFFECTIVE DATE: January 1, 2010

§ 58-3-280. Coverage for the diagnosis and treatment of lymphedema.
Every health benefit plan, as defined in G.S. 58-3-167, shall provide coverage for the diagnosis, evaluation, and treatment of lymphedema. The coverage required by this section shall include benefits for equipment, supplies, complex decongestive therapy, gradient compression garments, and self-management training and education, if the treatment is determined to be medically necessary and is provided by a licensed occupational or physical therapist or licensed nurse that has experience providing this treatment, or other licensed health care professional whose treatment of lymphedema is within the professional's scope of practice.
The same deductibles, coinsurance, and other limitations as apply to similar services covered under the health benefit plan apply to coverage for the diagnosis, evaluation, and treatment of lymphedema required to be covered under this section. Nothing in this section requires a health benefit plan to provide a separate set of benefit limitations or maximums for the diagnosis, evaluation, or treatment of lymphedema.
As used in this section, gradient compression garments:
1. Require a prescription;
2. Are custom-fit for the covered individual; and
3. Do not include disposable medical supplies such as over-the-counter compression or elastic knee-high or other stocking products. (2009-313, s.1.)