[Congressional Record Volume 154, Number 149 (Thursday, September 18, 2008)]
[Senate]
[Pages S9028-S9030]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Ms. SNOWE (for herself, Mr. Harkin, Mr. Inouye, and Mr. 
        Feingold):
  S. 3517. A bill to amend the Employee Retirement Income Security Act 
of 1974 and the Public Health Service Act to provide parity under group 
health plans and group health insurance coverage for the provision of 
benefits for prosthetic devices and components and benefits for other 
medical and surgical services; to the Committee on Health, Education, 
Labor, and Pensions.
  Ms. SNOWE. Today I rise with Senator Tom Harkin of Iowa to introduce 
bipartisan legislation aimed at reducing disability in our Nation. As 
the Congress moves this week to ensure the strength of the landmark 
Americans with Disabilities Act, we must continue to work to ensure 
that every American has the means to overcome physical impairment. I am 
honored to be joined today by Senator Harkin--who has long championed 
the ADA--as well as Senators Daniel Inouye, and Russ Feingold--as we 
act to ensure that those with group health insurance are able to access 
needed prosthetic care in order to lead full and independent lives.
  This year over 130,000 individuals will undergo amputation 
procedures, often as a complication of diabetes or other chronic 
disease. For such individuals an appropriate prosthetic limb reduces 
disability and allows them to maintain employment and lead more 
productive lives.
  Today many amputees receive prosthetics through their coverage by the 
VA, Medicare, Medicaid, or S-CHIP. Yet too often individuals without 
such coverage find that their private plan requires copayments for a 
needed prosthetic which they simply cannot afford, or imposes a 
``lifetime cap'' which prevents them from replacing an existing 
prosthetic when needed.
  So with an estimated two million individuals living with limb 
differences or loss in the United States, the impact of severely-
restricted prosthetic coverage can be devastating. This is even more so 
for the estimated 70,000 amputees under the age of 18. Sadly, we see 
those children particularly affected as their growth increases the 
frequency with which a prosthetic requires replacement. That can 
quickly exceed a parent's ability to meet copayment requirements--a 
coverage cap may deny access to a replacement prosthetic.
  So it is easy to see why 11 States--including my own State of Maine--
have enacted legislation to assure reasonable coverage of prosthetics, 
and why more than half of the States are now examining parity for 
prosthetics. Studies in different States have reported that the 
imposition of parity can be expected to raise monthly health plan 
premiums by approximately 12 to 50 cents a month. That low cost helps 
keep amputees productive, and avoids shifting health costs to public 
programs--simply because the needed prosthetic could not be obtained, 
and the individual saw their function and productivity decline until 
they had to rely on public assistance.
  That is so unnecessary and inappropriate. The legislation which we 
are introducing today--the Prosthetics Parity Act of 2008--will ensure 
that group health plans treat coverage of such prosthetic devices on 
par with other essential medical care covered by health insurance. It 
does not mandate coverage, but it does assure than when it is offered, 
it is not so restricted or capped that it does not assure an amputee of 
the prosthetic they require.
  As we move forward to ensure greater opportunity and accommodation 
for Americans with disabilities, it is so timely that we ensure the 
appropriate access to prosthetics to help reduce disability. I call on 
my colleagues to join us in supporting this legislation to further the 
vision of greater opportunity for those with disabilities.
  Mr. President, I ask unanimous consent that the text of the bill be 
printed in the Record.
  There being no objection, the text of the bill was ordered to be 
printed in the Record, as follows:

                                S. 3517

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. SHORT TITLE.

       This Act may be cited as the ``Prosthetics Parity Act of 
     2008''.

     SEC. 2. FINDINGS AND PURPOSE.

       (a) Findings.--Congress makes the following findings:
       (1) There are more than 1,800,000 people in the United 
     States living with limb loss.

[[Page S9029]]

       (2) Every year, there are more than 130,000 people in the 
     United States who undergo amputation procedures.
       (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 the 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 to unrealistic levels or not at 
     all and often restrict coverage over an individual's 
     lifetime, which shifts costs onto the Medicare and Medicaid 
     programs.
       (8) Eleven States have addressed this problem and have 
     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 
     and 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.
       (b) Purpose.--It is te purpose of this Act 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 that the terms and conditions 
     under which such benefits are provided for other benefits 
     under such plan.

     SEC. 3. PROSTHETICS PARITY.

       (a) ERISA.--
       (1) In general.--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:

     ``SEC. 714. PROSTHETICS PARITY.

       ``(a) In General.--In the case of a group health plan (or 
     health insurance coverage offered in connection with a group 
     health plan) that provides both medical and surgical benefits 
     for prosthetic devices and components (as defined under 
     subsection (d)(1))--
       ``(1) such benefits for prosthetic devices and components 
     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 
     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 shall 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 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 general.--In the case of a group health plan (or 
     health insurance coverage offered in connection with a group 
     health plan) that provides both medical and surgical benefits 
     and benefits for prosthetic devices and components, 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 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) Clarification.--Nothing in paragraph (1) shall be 
     construed as requiring that a group health plan (or health 
     insurance coverage offered in connection with a group health 
     plan) eliminate an out-of-network provider option from such 
     plan (or coverage) pursuant to the terms of the plan (or 
     coverage).
       ``(c) Additional Requirements.--
       ``(1) Prior authorization.--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 prosthetic devices and components 
     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 benefits.--Coverage for 
     required benefits for prosthetic devices and components under 
     this section shall 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.
       ``(3) Coverage for repair or replacement.--Benefits for 
     prosthetic devices and components required under this section 
     shall include coverage for the 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 limitations.--A group 
     health plan (or health insurance coverage offered in 
     connection with a group health plan) shall not impose any 
     annual or lifetime dollar limitation on benefits for 
     prosthetic devices and components required to be covered 
     under this section unless such limitation applies in the 
     aggregate to all medical and surgical benefits provided under 
     the plan (or coverage) and benefits for prosthetic devices 
     components.
       ``(d) Definitions.--In this section:
       ``(1) Prosthetic devices and components.--The term 
     `prosthetic devices and components' 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.
       ``(2) Financial requirements.--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.
       ``(3) Treatment limitations.--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.''.
       (2) Clerical amendment.--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 713 
     the following:

``Sec. 714. Prosthetics parity.''.

       (b) PHSA.--Subpart 2 of part A of title XXVII of the Public 
     Health Service Act (42 U.S.C. 300gg-4 et seq.) is amended by 
     adding at the end the following:

     ``SEC. 2707. PROSTHETICS PARITY.

       ``(a) In General.--In the case of a group health plan (or 
     health insurance coverage offered in connection with a group 
     health plan) that provides both medical and surgical benefits 
     for prosthetic devices and components (as defined under 
     subsection (d)(1))--
       ``(1) such benefits for prosthetic devices and components 
     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 
     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 shall 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 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 general.--In the case of a group health plan (or 
     health insurance coverage offered in connection with a group 
     health plan) that provides both medical and surgical benefits 
     and benefits for prosthetic devices and components, 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 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) Clarification.--Nothing in paragraph (1) shall be 
     construed as requiring that a group health plan (or health 
     insurance coverage offered in connection with a group health 
     plan) eliminate an out-of-network provider option from such 
     plan (or coverage) pursuant to the terms of the plan (or 
     coverage).
       ``(c) Additional Requirements.--
       ``(1) Prior authorization.--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 prosthetic devices

[[Page S9030]]

     and components 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 benefits.--Coverage for 
     required benefits for prosthetic devices and components under 
     this section shall 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.
       ``(3) Coverage for repair or replacement.--Benefits for 
     prosthetic devices and components required under this section 
     shall include coverage for the 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 limitations.--A group 
     health plan (or health insurance coverage offered in 
     connection with a group health plan) shall not impose any 
     annual or lifetime dollar limitation on benefits for 
     prosthetic devices and components required to be covered 
     under this section unless such limitation applies in the 
     aggregate to all medical and surgical benefits provided under 
     the plan (or coverage) and benefits for prosthetic devices 
     components.
       ``(d) Definitions.--In this section:
       ``(1) Prosthetic devices and components.--The term 
     `prosthetic devices and components' 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.
       ``(2) Financial requirements.--The term `financial 
     requirements' includes deductibles, coinsurance, co-payments, 
     other cost sharing, and limitations on the total amount that 
     may be paid by an enrollee with respect to benefits under the 
     plan or health insurance coverage and also includes the 
     application of annual and lifetime limits.
       ``(3) Treatment limitations.--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.''.
       (c) Effective Date.--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.

     SEC. 4. FEDERAL ADMINISTRATIVE RESPONSIBILITIES.

       (a) Assistance to Enrollees.--The Secretary of Labor, 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.
       (b) Audits.--The Secretary of Labor, 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).
       (c) GAO Study.--
       (1) Study.--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 the 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 prosthetics 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) Report.--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 committee 
     of Congress a report containing the results of the study 
     conducted under paragraph (1).
       (d) Regulations.--Not later than 1 year after the date of 
     the enactment of this Act, the Secretary of Labor, in 
     consultation with the Secretary of Health and Human Services, 
     shall promulgate final regulations to carry out this Act and 
     the amendments made by this Act.
                                 ______