SB265: SB265 Insurance; health benefit policy coverage for medically necessary orthotic devices and prosthetic devices; require

Currently Georgia law does not specifically require health insurers to cover orthotic devices (braces and supports worn outside the body) or prosthetic devices (artificial limbs and similar replacements). This bill adds a new section to Georgia's insurance code requiring all health benefit policies issued or renewed on or after January 1, 2026 to cover these devices when medically necessary for daily living, job duties, hygiene, or physical activity. The coverage is capped at three devices per affected limb per person every three years, but must include all materials, fitting, training, and repairs. Replacement is allowed sooner if a person's condition changes or repairs would cost more than 60 percent of a new device. Insurers can apply similar cost-sharing rules as for other medical devices but cannot single out this coverage for extra restrictions. The Insurance Commissioner must report on implementation by July 1, 2032, and can issue rules to carry out the law. The law would take effect as soon as the Governor signs it, though coverage under state contracts depends on future state funding.

• Requires all health benefit policies issued or renewed on or after January 1, 2026 to cover medically necessary orthotic and prosthetic devices, including their materials and components.
• Limits covered devices to no more than three per affected limb per person during any three-year period, while covering fittings, training, repairs, and consumable parts like liners and socks.
• Allows earlier replacement of a device or socket if there is documented physiological change, irreparable damage, or repair costs exceeding 60 percent of a new device's cost.
• Lets insurers apply the same cost-sharing rules used for other medical devices, but bars rules that apply only to this coverage, and allows different treatment for out-of-network providers within limits.
• Requires the Insurance Commissioner to report to House and Senate insurance committees by July 1, 2032 on claims data for this coverage, and to write implementing rules.

People who use orthotic braces or prosthetic limbs, health insurers offering policies regulated under Georgia's insurance code (O.C.G.A. Title 33), and the state Insurance Commissioner's office, which must collect data and issue rules to implement the new coverage requirement.

Georgians who need braces, artificial limbs, or similar devices for daily activities, work, hygiene, or exercise would gain a guaranteed insurance benefit covering the device, its parts, fitting, training, and repairs, subject to a three-devices-per-limb cap every three years and standard cost-sharing.

• Adds new Code Section 33-24-59.34 to Title 33 defining terms like 'orthotic device,' 'prosthetic device,' and 'medically necessary,' tied to existing definitions in O.C.G.A. §§ 33-24-59.32, 33-24-59.21, and 33-46-4.
• Subsection (b) requires coverage for devices needed for daily living, job-related activities, personal hygiene, and physical activities like running or swimming, for policies issued or renewed after January 1, 2026.
• Subsection (c) caps coverage at three devices per limb per person every three years and lists covered materials, components, fitting, training, and repairs.
• Subsection (d) sets conditions under which early replacement of a device or socket is considered medically necessary, including damage, physiological change, or high repair costs.
• Subsection (e) exempts insurers from covering replacement or repair caused by misuse, malicious damage, gross neglect, loss, or theft.
• Subsection (f) sets how this coverage relates to other benefit requirements, cost-sharing rules, and out-of-network limits.
• Subsection (h) requires a Commissioner's report by July 1, 2032 using insurer-submitted claims data from 2026 to 2030.
• Section 2 makes the law effective upon the Governor's signature, with coverage under state contracts subject to future appropriations (state funding).

1. 2025-02-27Senate Read and Referred (Senate)
2. 2025-02-26Senate Hopper (Senate)

• Shawn Still (R, SD-048)Primary sponsor
• Ben Watson (R, SD-001)

• health insurance coverage
• prosthetic devices
• orthotic devices
• disability accommodations
• insurance regulation