SB101: SB101 Duchenne Muscular Dystrophy; testing in the newborn screening system; require

25 LC 60 0167S Senate Bill 101 By: Senators Robertson of the 29th, Hatchett of the 50th, Payne of the 54th, Williams of the 25th, Still of the 48th and others AS PASSED A BILL TO BE ENTITLED AN ACT To amend Title 33 of the Official Code of Georgia Annotated, relating to insurance, so as to1 require certain health benefit policy coverage for medically necessary orthotic devices and2 prosthetic devices and their materials and components; to provide for definitions; to provide3 for requirements; to provide for reporting; to provide for rules and regulations; to provide for4 related matters; to provide for an effective date; to repeal co nflicting laws; and for other5 purposes.6 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:7 SECTION 1.8 Title 33 of the Official Code of Georgia Annotated, relating to insurance, is amended in9 Chapter 24, relating to insurance generally, by adding a new Code section to read as follows:10 "33-24-59.34.11 (a) As used in this Code section, the term:12 (1) 'Cost-sharing requirement' shall have the same meaning as set forth in Code13 Section 33-24-59.32.14 (2) 'Covered person' means an individual covered under a health benefit policy.15 S. B. 101 - 1 - 25 LC 60 0167S (3) 'Health benefit policy' means any individual or group plan , policy, or contract for16 healthcare services issued, delivered, issued for delivery, or renewed in this state by an17 insurer that provides major medical benefits. Such term shall not include any plans,18 policies, or contracts executed by the state on behalf of state employees under Article 119 of Chapter 18 of Title 45 and shall not apply to the provision of healthcare services20 pursuant to a contract entered into by an insurer and the Depar tment of Community21 Health for recipients of Medicaid. Such term shall not include self-funded, employer22 sponsored health insurance plans subject to the exclusive juris diction of the federal23 Employee Retirement Income Security Act of 1974, as codified an d amended at 2924 U.S.C. Section 1001, et seq.25 (4) 'Health insurer' means any person, corporation, or other entity authorized to provide26 health benefit policies under this title.27 (5) 'Medically necessary' shall have the same meaning as set f orth in Code28 Section 33-46-4 and shall be in accordance with nationally recognized clinical practice29 guidelines.30 (6) 'Nationally recognized clinical practice guidelines' means evidence based clinical31 practice guidelines developed by independent organizations or m edical professional32 societies utilizing a transparent methodology and reporting structure and with a conflict33 of interest policy. Such guidelines establish standards of care informed by a systematic34 review of evidence and an assessment of the benefits and risks of alternative care options35 and include recommendations intended to optimize patient care.36 (7) 'Orthotic device' or 'orthosis' means a custom fabricated or custom fitted device that37 is designed, fabricated, modified, or fitted to correct, suppor t, or compensate for a38 neuromusculoskeletal disorder or acquired c ondition for the pur pose of stabilizing,39 stretching, or immobilizing a body part, improving alignment, p reventing deformities,40 protecting against injury, or assisting with motion or function, and is worn on the outside41 of the body to help with such structural or functional problems . Such term does not42 S. B. 101 - 2 - 25 LC 60 0167S include fabric or elastic supports, corsets, arch supports, low-temperature plastic splints,43 trusses, elastic hoses, canes, crutches, soft cervical collars, dental appliances, or other44 similar devices that are carried in stock and sold as over-the- counter items by a drug45 store, department store, corset shop, or surgical supply facility.46 ( 8 ) ' P r o s t h e t i c d e v i c e ' o r ' p r o s t h e s i s ' m e a n s a c u s t o m d e s i g n ed, fabricated, fitted,47 modified, or fitted and modified device to replace an absent ex ternal body part for48 purposes of restoring physiological function or cosmesis or bot h. Such term does not49 include artificial eyes or ears; dental appliances; cosmetic de vices such as artificial50 breasts, eyelashes, or wigs; or other devices that do not have a significant impact on51 mobility or the musculoskeletal functions of the body.52 (b) All health benefit policies renewed or issued on or after January 1, 2026, shall include53 coverage for orthotic devices and prosthetic devices that are medically necessary for:54 (1) Activities of daily living;55 (2) Essential job related activities;56 (3) Personal hygiene related activities, including, but not limited to, showering, bathing,57 and toileting; or58 (4) Physical activities, including, but not limited to, runnin g, biking, swi mming, and59 strength training, so as to maximize the covered person's whole body health and both60 upper and lower limb function.61 (c) The coverage provided for in this Code section shall inclu de no more than three62 orthotic devices or prosthetic devices per affected limb per co vered person during any63 three-year period. Such coverage shall include:64 (1) All materials and components for the use of the orthotic device or prosthetic device,65 including:66 (A) The orthosis or prosthesis;67 (B) Structural components such as the socket;68 (C) Suspension mechanisms such as the pin, lock, suction, and elevated vacuum;69 S. B. 101 - 3 - 25 LC 60 0167S (D) Hip joint, knee joint, foot, alignable parts, and terminal device;70 (E) Connective components such as pads, bands, and cushions; and71 (F) Consumable items such as socks, sleeves, and liners;72 (2) Formulation of the device's design, fabrication, measurements and fittings;73 (3) Education and training on using and maintaining such device; and74 (4) The repair of such device and its components.75 (d)(1) The replacement of an orthotic device or prosthetic device and its materials and76 components when such device is less than three years old shall be medically necessary77 if there is adequate documentation of a change in the physiolog ical condition of the78 covered person, an irreparable change in the condition of the d evice or any of its79 components, or the condition of the device or a component of the device requires repairs80 and the cost of such repairs would be more than 60 percent of the cost of the device.81 (2) A socket replacement shall be medically necessary if there is adequate documentation82 of a physiological need, including, but not limited to, a chang e in the residual limb, a83 functional need change, irreparable damage, or wear and tear due to excessive weight of84 a covered person or physical demands of an active covered person.85 (e) A health insurer shall not be required to replace or repai r a n o r t h o t i c d e v i c e o r86 prosthetic device due to misuse, malicious damage, gross neglect, loss, or theft.87 (f) The coverage provided for in this Code section:88 (1) Shall be considered as habilitative or rehabilitative benefits for purposes of any state89 or federal requirements for coverage of essential health benefits;90 (2) Shall be comparable to coverage for other medical and surg ical benefits under the91 health benefit policy, including restorative internal devices;92 (3) May be subject to the same cost-sharing requirements that apply to other medical93 devices and services covered by the health benefit policy; provided, however, that such94 requirements shall not be solely applicable to such coverage; and95 S. B. 101 - 4 - 25 LC 60 0167S (4) May be limited, or the cost-sharing requirements for such coverage may be altered96 for out-of-network providers; provided, however, that any limitations shall not be more97 restrictive than the restrictions and requirements applicable t o the out-of-network98 coverage for the policy's medical or surgical coverage.99 (g) Nothing in this Code section shall be construed to prohibit a health insurer from issuing100 or renewing a health benefit policy which provides benefits gre ater than the minimum101 benefits required under this Code section or from issuing or re newing a policy which102 provides benefits which are generally more favorable to the cov ered person than those103 required under this Code section.104 (h) By July 1, 2032, the Commissioner shall submit a report to the House Committee on105 Insurance and the Senate Insurance and Labor Committee regardin g the implementation106 of the coverage required under this Code section. All health insurers issuing or renewing107 health benefit policies subject to the provisions of this Code section shall provide the108 department with all data requested by the department for inclus ion in such report,109 including, but limited to, the total number of claims submitted, the total number of claims110 paid, and the total amount of claims paid for the coverage provided for by this Code section111 for policy years from 2026 to 2030.112 (i) The Commissioner shall promulgate rules and regulations necessary to implement the113 provisions of this Code section."114 SECTION 2.115 This Act shall become effective upon its approval by the Governor or upon its becoming law116 without such approval.117 SECTION 3.118 All laws and parts of laws in conflict with this Act are repealed.119 S. B. 101 - 5 -