Sec. 3. Prosthetics and custom orthotics fairness in coverage

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Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1185 et seq. ) is amended by adding at the end the following: In the case of a group health plan (or health insurance coverage offered in connection with a group health plan) that provides medical and surgical benefits and also provides benefits for prosthetics or custom orthotics (as defined under paragraphs

(1)and

(2)of subsection (e)) (or both)— such benefits for prosthetics or custom orthotics (or both) under the plan (or coverage) shall be provided under terms and conditions that are no less favorable than the terms and conditions applicable to substantially all medical and surgical benefits provided under the plan (or coverage); such benefits for prosthetics or custom orthotics (or both) under the plan (or coverage) may not be subject to separate financial requirements (as defined in subsection (d)(3)) that are applicable only with respect to such benefits, and any financial requirements applicable to such benefits shall be no more restrictive than the financial requirements applicable to substantially all medical and surgical benefits provided under the plan (or coverage); and any treatment limitations (as defined in subsection (d)(4)) applicable to such benefits for prosthetics or custom orthotics (or both) under the plan (or coverage) may not be more restrictive than the treatment limitations applicable to substantially all medical and surgical benefits provided under the plan (or coverage). A group health plan (or health insurance coverage offered in connection with a group health plan) described in subsection

(a)that does not provide coverage for benefits outside of a network shall ensure that such provider network is adequate to ensure enrollee access to prosthetic and custom orthotic devices and related services provided by appropriately credentialed practitioners and accredited suppliers of prosthetics and custom orthotics. In the case of a group health plan (or health insurance coverage offered in connection with a group health plan) that requires, as a condition of coverage or payment for prosthetics or custom orthotics (or both) under the plan (or coverage), prior authorization, such prior authorization must be required in the same manner as prior authorization is required by the plan (or coverage) as a condition of coverage or payment for all similar medical and surgical benefits provided under the plan (or coverage). Coverage for required benefits for prosthetics and custom orthotics under this section may be limited to coverage of the most appropriate device or component model that meets the medical requirements of the patient, as determined by the treating physician of the patient involved. Benefits for prosthetics and custom orthotics required under this section shall include coverage for the repair or replacement of prosthetics and custom orthotics, if the repair or replacement is due to normal wear and tear, irreparable damage, a change in the condition of the patient as determined by the treating physician, or otherwise determined appropriate by the treating physician of the patient involved. In this section: The term prosthetics means those devices and components that may be used to replace, in whole or in part, an arm or leg, as well as the services required to do so and includes external breast prostheses incident to mastectomy resulting from breast cancer. The term custom orthotics means the following: Custom-fabricated orthotics and related services, which include custom-fabricated devices that are individually made for a specific patient, as well as all services and supplies that are medically necessary for the effective use of the orthotic device and instructing the patient in the use of the device. No other patient would be able to use this particular orthosis. A custom-fabricated orthosis is a device which is fabricated based on clinically derived and rectified castings, tracings, measurements, or other images (such as x-rays) of the body part. The fabrication may involve using calculations, templates and component parts. This process requires the use of basic materials and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling and finishing prior to fitting on the patient. Custom-fabricated devices may be furnished only by an appropriately credentialed (certified or licensed) practitioner and accredited supplier in Orthotics or Prosthetics. Such devices and related services are represented by the set of L-codes under the Healthcare Common Procedure Coding System describing this care listed on the date of enactment of this section in Centers for Medicare & Medicaid Services Transmittal 656. Custom-fitted high orthotics and related services, which include prefabricated devices that are manufactured with no specific patient in mind, but that are appropriately sized, adapted, modified, and configured (with the required tools and equipment) to a specific patient in accordance with a prescription, and which no other patient would be able to use, as well as all services and supplies that are medically necessary for the effective use of the orthotic device and instructing the patient in the use of the device. Custom-fitted high devices may be furnished only by an appropriately credentialed (certified or licensed) practitioner and accredited supplier in Orthotics or Prosthetics. Such devices and related services are represented by the existing set of L-codes under the Healthcare Common Procedure Coding System describing this care listed on the date of enactment of this section in Centers for Medicare & Medicaid Services Transmittal 656. For purposes of subparagraphs

(A)and (B), Centers for Medicare & Medicaid Services Transmittal 656, upon modification or reissuance by the Centers for Medicare & Medicaid Services to reflect new code additions and coding changes for prosthetics and custom orthotics, shall be the version of the Transmittal used for purposes of such subparagraphs. The term financial requirements includes deductibles, coinsurance, co-payments, other cost sharing, and limitations on the total amount that may be paid by a participant or beneficiary with respect to benefits under the plan or health insurance coverage. The term treatment limitations includes limits on the frequency of treatment, number of visits, specific prescribed components, limits that are more broadly applicable to durable medical equipment, or other similar limits on the amount, duration, or scope of treatment. For purposes of this section, prosthetics and custom orthotics shall be treated as distinct from durable medical equipment. . The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 is amended by inserting after the item relating to section 714 the following: Sec. 715. Additional market reforms. Sec. 716. Prosthetics and custom orthotics parity. . Title XXVII of the Public Health Service Act is amended by inserting after section 2728 of such Act ( 42 U.S.C. 300gg–28 ), as redesignated by section 1001(2) of the Patient Protection and Affordable Care Act ( Public Law 111–148 ), the following: In the case of a group health plan, or a health insurance issuer offering group or individual health insurance coverage, that provides medical and surgical benefits and also provides benefits for prosthetics or custom orthotics (as defined under paragraphs

(1)and

(2)of subsection (e)) (or both)— such benefits for prosthetics or custom orthotics (or both) under the plan or coverage shall be provided under terms and conditions that are no less favorable than the terms and conditions applicable to substantially all medical and surgical benefits provided under the plan or coverage; such benefits for prosthetics or custom orthotics (or both) under the plan or coverage may not be subject to separate financial requirements (as defined in subsection (e)(2)) that are applicable only with respect to such benefits, and any financial requirements applicable to such benefits shall be no more restrictive than the financial requirements applicable to substantially all medical and surgical benefits provided under the plan or coverage; and any treatment limitations (as defined in subsection (e)(3)) applicable to such benefits for prosthetics or custom orthotics (or both) under the plan or coverage may not be more restrictive than the treatment limitations applicable to substantially all medical and surgical benefits provided under the plan or coverage. A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in subsection

(a)that does not provide coverage for benefits outside of a network shall ensure that such provider network is adequate to ensure enrollee access to prosthetic and custom orthotic devices and related services provided by appropriately credentialed practitioners and accredited suppliers of prosthetics and custom orthotics. In the case of a group health plan, or health insurance issuer offering group or individual health insurance coverage, that requires, as a condition of coverage or payment for prosthetics or custom orthotics (or both) under the plan or coverage, prior authorization, such prior authorization must be required in the same manner as prior authorization is required by the plan or coverage as a condition of coverage or payment for all similar medical and surgical benefits provided under the plan or coverage. Coverage for required benefits for prosthetics and custom orthotics under this section may be limited to coverage of the most appropriate device or component model that adequately meets the medical requirements of the patient, as determined by the treating physician of the patient involved. Benefits for prosthetics and custom orthotics required under this section shall include coverage for the repair or replacement of prosthetics and custom orthotics, if the repair or replacement is due to normal wear and tear, irreparable damage, a change in the condition of the patient as determined by the treating physician, or otherwise determined appropriate by the treating physician of the patient involved. In this section: The term prosthetics means those devices and components that may be used to replace, in whole or in part, an arm or leg, as well as the services required to do so and includes external breast prostheses incident to mastectomy resulting from breast cancer. The term custom orthotics means the following: Custom-fabricated orthotics and related services, which include custom-fabricated devices that are individually made for a specific patient, as well as all services and supplies that are medically necessary for the effective use of the orthotic device and instructing the patient in the use of the device. No other patient would be able to use this particular orthosis. A custom-fabricated orthosis is a device which is fabricated based on clinically derived and rectified castings, tracings, measurements, or other images (such as x-rays) of the body part. The fabrication may involve using calculations, templates and component parts. This process requires the use of basic materials and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling and finishing prior to fitting on the patient. Custom-fabricated devices may be furnished only by an appropriately credentialed (certified or licensed) practitioner and accredited supplier in Orthotics or Prosthetics. Such devices and related services are represented by the set of L-codes under the Healthcare Common Procedure Coding System describing this care listed on the date of enactment of this section in Centers for Medicare & Medicaid Services Transmittal 656. Custom-fitted high orthotics and related services, which include prefabricated devices that are manufactured with no specific patient in mind, but that are appropriately sized, adapted, modified, and configured (with the required tools and equipment) to a specific patient in accordance with a prescription, and which no other patient would be able to use, as well as all services and supplies that are medically necessary for the effective use of the orthotic device and instructing the patient in the use of the device. Custom-fitted high devices may be furnished only by an appropriately credentialed (certified or licensed) practitioner and accredited supplier in Orthotics or Prosthetics. Such devices and related services are represented by the existing set of L-codes under the Healthcare Common Procedure Coding System describing this care listed on the date of enactment of this section in Centers for Medicare & Medicaid Services Transmittal 656. For purposes of subparagraphs

(A)and (B), Centers for Medicare & Medicaid Services Transmittal 656, upon modification or reissuance by the Centers for Medicare & Medicaid Services to reflect new code additions and coding changes for prosthetics and custom orthotics, shall be the version of the Transmittal used for purposes of such subparagraphs. The term financial requirements includes deductibles, coinsurance, co-payments, other cost sharing, and limitations on the total amount that may be paid by a participant or beneficiary with respect to benefits under the plan or health insurance coverage. The term treatment limitations includes limits on the frequency of treatment, number of visits, specific prescribed components, and limits that are more broadly applicable to durable medical equipment, or other similar limits on the amount, duration, or scope of treatment. For purposes of this section, prosthetics and custom orthotics shall be treated as distinct from durable medical equipment. . For purposes of applying section 2729 of the Public Health Service Act, as inserted by paragraph (1), to individual health insurance coverage before 2014, the provisions of such section shall be treated as also included under part B of title XXVII of the Public Health Service Act. Subchapter B of chapter 100 of subtitle K of the Internal Revenue Code of 1986 is amended by adding after section 9813 the following: In the case of a group health plan (or health insurance coverage offered in connection with a group health plan) that provides medical and surgical benefits and also provides benefits for prosthetics or custom orthotics (as defined under paragraphs

(1)and

(2)of subsection (e)) (or both)— such benefits for prosthetics or custom orthotics (or both) under the plan (or coverage) shall be provided under terms and conditions that are no less favorable than the terms and conditions applicable to substantially all medical and surgical benefits provided under the plan (or coverage); such benefits for prosthetics or custom orthotics (or both) under the plan (or coverage) may not be subject to separate financial requirements (as defined in subsection (e)(2)) that are applicable only with respect to such benefits, and any financial requirements applicable to such benefits shall be no more restrictive than the financial requirements applicable to substantially all medical and surgical benefits provided under the plan (or coverage); and any treatment limitations (as defined in subsection (e)(3)) applicable to such benefits for prosthetics or custom orthotics (or both) under the plan (or coverage) may not be more restrictive than the treatment limitations applicable to substantially all medical and surgical benefits provided under the plan (or coverage). A group health plan (or health insurance coverage offered in connection with a group health plan) described in subsection

(a)that does not provide coverage for benefits outside of a network shall ensure that such provider network is adequate to ensure enrollee access to prosthetic and custom orthotic devices and related services provided by appropriately credentialed practitioners and accredited suppliers of prosthetics and custom orthotics. In the case of a group health plan (or health insurance coverage offered in connection with a group health plan) that requires, as a condition of coverage or payment for prosthetics or custom orthotics (or both) under the plan (or coverage), prior authorization, such prior authorization must be required in the same manner as prior authorization is required by the plan (or coverage) as a condition of coverage or payment for all similar medical and surgical benefits provided under the plan (or coverage). Coverage for required benefits for prosthetics and custom orthotics under this section may be limited to coverage of the most appropriate device or component model that meets the medical requirements of the patient, as determined by the treating physician of the patient involved. Benefits for prosthetics and custom orthotics required under this section shall include coverage for the repair or replacement of prosthetics and custom orthotics, if the repair or replacement is due to normal wear and tear, irreparable damage, a change in the condition of the patient as determined by the treating physician, or otherwise determined appropriate by the treating physician of the patient involved. The Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, shall provide assistance to enrollees under plans or coverage to which the amendment made by section 3 apply with any questions or problems with respect to compliance with the requirements of such amendment. The Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, shall provide for the conduct of random audits of group health plans (and health insurance coverage offered in connection with such plans) to ensure that such plans (or coverage) are in compliance with the amendments made by section (3). In this section: The term prosthetics means those devices and components that may be used to replace, in whole or in part, an arm or leg, as well as the services required to do so and includes external breast prostheses incident to mastectomy resulting from breast cancer. The term custom orthotics means the following: Custom-fabricated orthotics and related services, which include custom-fabricated devices that are individually made for a specific patient, as well as all services and supplies that are medically necessary for the effective use of the orthotic device and instructing the patient in the use of the device. No other patient would be able to use this particular orthosis. A custom-fabricated orthosis is a device which is fabricated based on clinically derived and rectified castings, tracings, measurements, or other images (such as x-rays) of the body part. The fabrication may involve using calculations, templates and component parts. This process requires the use of basic materials and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling and finishing prior to fitting on the patient. Custom-fabricated devices may be furnished only by an appropriately credentialed (certified or licensed) practitioner and accredited supplier in Orthotics or Prosthetics. Such devices and related services are represented by the set of L-codes under the Healthcare Common Procedure Coding System describing this care listed on the date of enactment of this section in Centers for Medicare & Medicaid Services Transmittal 656. Custom-fitted high orthotics and related services, which include prefabricated devices that are manufactured with no specific patient in mind, but that are appropriately sized, adapted, modified, and configured (with the required tools and equipment) to a specific patient in accordance with a prescription, and which no other patient would be able to use, as well as all services and supplies that are medically necessary for the effective use of the orthotic device and instructing the patient in the use of the device. Custom-fitted high devices may be furnished only by an appropriately credentialed (certified or licensed) practitioner and accredited supplier in Orthotics or Prosthetics. Such devices and related services are represented by the existing set of L-codes under the Healthcare Common Procedure Coding System describing this care listed on the date of enactment of this section in Centers for Medicare & Medicaid Services Transmittal 656. For purposes of subparagraphs

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U.S. Code

Standards relating to benefits for mothers and newborns
§ 1185

2 references not yet in our index

42 USC 300gg–28
Pub. L. 111-148

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cites case law

Sec. 3

Prosthetics and custom orthotics fairness in coverage

U.S.C.§ 1185

Cite42 USC 300gg–28

Pub. L.Pub. L. 111-148

Cites 3Cited by 0 across 0 sources