1.This Act may be cited as the
Prosthetic and Custom Orthotic Parity
Act of 2009
.
2.
(a)Congress finds the following:
(1)There are more
than 1,800,000 people in the United States living with limb loss.
(2)Every year, there
are more than 130,000 people in the United States who undergo
amputation.
(3)In addition,
United States military personnel serving in Iraq and Afghanistan and around the
world have sustained traumatic injuries resulting in amputation.
(4)The number of
amputations in the United States is projected to increase in the years ahead
due to rising incidence of diabetes and other chronic illness.
(5)Those suffering
from limb loss can and want to regain their lives as productive members of
society.
(6)Prosthetic devices
enable amputees to continue working and living productive lives.
(7)Insurance companies
have begun to limit reimbursement of prosthetic equipment costs at unrealistic
levels or not at all and often restrict coverage over a person’s lifetime,
which shifts costs onto the Medicare and Medicaid programs.
(8)Eleven States have
addressed this problem and have enacted prosthetic parity legislation.
(9)Prosthetic parity
legislation has been introduced and is being actively considered in 30
States.
(10)The States in
which prosthetic parity laws have been enacted have found there to be minimal
or no increases in insurance premiums and have reduced Medicare and Medicaid
costs.
(11)Prosthetic parity
legislation will not add to the size of government or to the costs associated
with the Medicare or Medicaid programs.
(12)If coverage for
prosthetic devices and components are offered by a group health insurance
policy, then providing such coverage of prosthetic devices on par with other
medical and surgical benefits will not increase the incidence of amputations or
the number of individuals for which a prosthetic device would be medically
necessary and appropriate.
(13)In States where
prosthetic parity legislation has been enacted, amputees are able to return to
a productive life, State funds have been saved, and the health insurance
industry has continued to prosper.
(14)Prosthetic
services allow people to return more quickly to their preexisting work.
(15)Spina bifida
occurs in 7 out of every 10,000 live births in the United States.
(16)For children with
spina bifida, access to a custom orthotic device impacts both their short and
long term mobility, their muscle strength, and overall quality of life. As they
mature, the orthotic device allows them to maintain their maximum level of
functionality. This has a profound impact on their ability to become and remain
independent and productive members of the community.
(17)Cerebral palsy is
one of the most common congenital (existing before birth or at birth) disorders
of childhood. About 10,000 babies per year in the United States will develop
cerebral palsy.
(18)The purpose of a
custom orthotic device for people with cerebral palsy is to protect, such as
stabilizing a fracture during healing; to prevent deformity, such as stretching
braces worn while the person sleeps, to help prevent muscle contractures; and
to improve function. This can help kids with cerebral palsy achieve maximum
potential in growth and development.
(19)If coverage for
prosthetic and custom orthotic devices and related services is offered to
individuals by a group health insurance policy, then providing such coverage of
prosthetic and orthotic devices on par with other medical and surgical benefits
will not increase the incidence of amputations or the number of individuals for
which a prosthetic or custom orthotic device would be medically necessary and
appropriate.
(b)The
purpose of this Act is to require that each group health plan that provides
both coverage for prosthetic devices and components and medical and surgical
benefits, provide such coverage under terms and conditions that are no less
favorable than the terms and conditions under which such benefits are provided
under such plan.
3.Prosthetics and
custom orthotic device parity under ERISA
(a)Subpart B of part 7
of subtitle B of title I of the Employee Retirement Income Security Act of 1974
is amended by inserting after section 713 (29 U.S.C. 1185b) the following new
section:
715.Prosthetics and
custom orthotic device parity
(a)In the case of a
group health plan (or health insurance coverage offered in connection with such
a plan) that provides both medical and surgical benefits and benefits for
prosthetic devices and components and orthotic devices (as defined under
subsection (d)(1))—
(1)such benefits for prosthetic devices and
components and custom orthotic devices and related services 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);
(2)such benefits for prosthetic devices and
components and custom orthotic devices and related services under the plan (or
coverage) may not be subject to separate financial requirements (as defined in
subsection (d)(2)) that are applicable only with respect to such benefits, and
any financial requirements applicable to such benefits may be no more
restrictive than the financial requirements applicable to substantially all
medical and surgical benefits provided under the plan (or coverage); and
(3)any treatment limitations (as defined in
subsection (d)(3)) applicable to such benefits for prosthetic devices and
components and custom orthotic devices and related services 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).
(b)In-network and
out-of-network standards
(1)In the case of a
group health plan (or health insurance coverage offered in connection with such
a plan) that provides both medical and surgical benefits and benefits for
prosthetic devices and components and custom orthotic devices and related
services, and that provides both in-network benefits for prosthetic devices and
components and out-of-network benefits for prosthetic devices and components,
the requirements of this section shall apply separately with respect to
benefits provided under the plan (or coverage) on an in-network basis and
benefits provided under the plan (or coverage) on an out-of-network
basis.
(2)Nothing
in paragraph (1) shall be construed as requiring that a group health plan (or
health insurance coverage offered in connection with such a plan) eliminate an
out-of-network provider option from such plan (or coverage) pursuant to the
terms of the plan (or coverage).
(c)
(1)In the case of
a group health plan (or health insurance coverage offered in connection with
such a plan) that requires, as a condition of coverage or payment for
prosthetic devices and custom orthotic devices and related services 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 benefits
provided under the plan (or coverage).
(2)Limitation on
mandated benefitsRequired
benefits for prosthetic devices and custom orthotic devices and related
services under this section are limited to the most appropriate model that
adequately meets the medical requirements of the patient, as determined by the
treating physician of the patient.
(3)Coverage for
repair or replacementBenefits for prosthetic devices and custom
orthotic devices and related services required under this section shall include
coverage for repair or replacement of prosthetic devices and components, if the
repair or replacement is determined appropriate by the treating physician of
the patient involved.
(4)Annual or
lifetime dollar limitationsA
group health plan (or health insurance coverage offered in connection with such
a plan) may not impose any annual or lifetime dollar limitation on benefits for
prosthetic devices and custom orthotic devices and related services unless such
limitation applies in the aggregate to all medical and surgical benefits
provided under the plan (or coverage) and benefits for prosthetic devices and
components.
(d)For
the purposes of this section:
(1)Prosthetic
devices and componentsThe
term prosthetic devices and components means such devices and
components which 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.
(2)Custom orthotic
devices and related servicesThe term custom orthotic
devices and related services
means the following:
(A)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 medically necessary for the effective use of the orthotic device,
including formulating its design, fabrication, material and component
selection, measurements, fittings, and static and dynamic alignments, and
instructing the patient in the use of the device. No other patient would be
able to use this item. A custom fabricated item is a device which is fabricated
based on clinically derived and rectified castings, tracings, measurements,
and/or other images (such as x-rays) of the body part. The fabrication may
involve using calculations, templates and components. This process requires the
use of basic materials including, but not limited to plastic, metal, leather or
cloth in the form of uncut or unshaped sheets, bars, or other basic forms 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 or accredited supplier in
orthotics and/or prosthetics. These devices and services are represented by the
existing set of L-codes describing this care currently listed in Centers for
Medicare and Medicaid Services Transmittal 656.
(B)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
medically necessary for the effective use of the orthotic device, including
formulating its design, fabrication, material and component selection,
measurements, fittings, and static and dynamic alignments, 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 or
accredited supplier in orthotics and/or prosthetics. These devices and services
are represented by the existing set of L-codes describing this care currently
listed in Centers for Medicare and Medicaid Services Transmittal 656.
(3)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 and also includes the application of annual and
lifetime limits.
(4)The term
treatment limitations includes limits on the frequency of
treatment, number of visits, days of coverage, or other similar limits on the
scope or duration of
treatment.
.
(b)The table of contents in section 1 of such Act is
amended by inserting after the item relating to section 713 the following new
item:
Sec. 715. Prosthetics and custom orthotic
device
parity.
.
(c)The amendments made by this section shall apply with respect
to group health plans (and health insurance coverage offered in connection with
group health plans) for plan years beginning on or after the date of the
enactment of this Act.
4.Federal
administrative responsibilities
(a)Assistance to
Plan Participants and BeneficiariesThe Secretary of Labor shall provide for
assistance to participants and beneficiaries under such plans with any
questions or problems regarding compliance with the requirements of this
section.
(b)The Secretary of Labor 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 are
in compliance with section 715 of the Employee Retirement Income Security Act
of 1974, as added by section 3.
(c)
(1)The
Comptroller General of the United States shall conduct a study that evaluates
the effect of the implementation of the amendments made by this Act on the cost
of health insurance coverage, on access to health insurance coverage (including
the availability of in-network providers), on the quality of health care, on
benefits and coverage for prosthetic devices and components, on any additional
cost or savings to group health plans, on State prosthetic devices and
components benefit mandate laws, on the business community and the Federal
Government, and on other issues as determined appropriate by the Comptroller
General.
(2)Not
later than 2 years after the date of the enactment of this Act, the Comptroller
General of the United States shall prepare and submit to the appropriate
committees of Congress a report containing the results of the study conducted
under paragraph (1).
(d)Not
later than 1 year after the date of the enactment of this Act, the Secretary of
Labor shall promulgate final regulations to carry out this Act and the
amendments made by this Act.