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

25 LC 52 0771 Senate Bill 265 By: Senators Still of the 48th and Watson of the 1st 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 health benefit policy coverage for medically necessary orthotic devices and prosthetic2 devices and their materials and components; to provide for defi nitions; to provide for3 requirements; to provide for reporting; to provide for rules an d regulations; to provide for4 related matters; to provide for an effective date and appropriations; to repeal conflicting laws;5 and for other 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. 265 - 1 - 25 LC 52 0771 (3) 'Health benefit policy' shall have the same meaning as set forth in Code16 Section 33-24-59.21.17 (4) 'Health insurer' means any person, corporation, or other entity authorized to provide18 health benefit policies under this title.19 (5) 'Medically necessary' shall have the same meaning as set f orth in Code20 Section 33-46-4 and shall be in accordance with nationally recognized clinical practice21 guidelines.22 (6) 'Nationally recognized clinical practice guidelines' means evidence based clinical23 practice guidelines developed by independent organizations or m edical professional24 societies utilizing a transparent methodology and reporting structure and with a conflict25 of interest policy. Such guidelines establish standards of care informed by a systematic26 review of evidence and an assessment of the benefits and risks of alternative care options27 and include recommendations intended to optimize patient care.28 (7) 'Orthotic device' or 'orthosis' means a custom fabricated or custom fitted device that29 is designed, fabricated, modified, or fitted to correct, suppor t , o r c o m p e n s a t e f o r a30 neuromusculoskeletal disorder or acquired condition for the pur pose of stabilizing,31 stretching, or immobilizing a body part, improving alignment, p reventing deformities,32 protecting against injury, or assisting with motion or function, and is worn on the outside33 of the body to help with such structural or functional problems . Such term does not34 include fabric or elastic supports, corsets, arch supports, low-temperature plastic splints,35 trusses, elastic hoses, canes, crutches, soft cervical collars, dental appliances, or other36 similar devices that are carried in stock and sold as over-the- counter items by a drug37 store, department store, corset shop, or surgical supply facility.38 (8) 'Prosthetic device' or 'prosthesis' means a custom designe d, fabricated, fitted,39 modified, or fitted and modified device to replace an absent ex ternal body part for40 purposes of restoring physiological function or cosmesis or bot h. Such term does not41 include artificial eyes or ears; dental appliances; cosmetic de vices such as artificial42 S. B. 265 - 2 - 25 LC 52 0771 breasts, eyelashes, or wigs; or other devices that do not have a significant impact on43 mobility or the musculoskeletal functions of the body.44 (b) All health benefit policies renewed or issued on or after January 1, 2026, shall include45 coverage for orthotic devices and prosthetic devices that are medically necessary for:46 (1) Activities of daily living;47 (2) Essential job related activities;48 (3) Personal hygiene related activities, including, but not limited to, showering, bathing,49 and toileting; or50 (4) Physical activities, including, but not limited to, runnin g, biking, swimming, and51 strength training, so as to maximize the covered person's whole body health and both52 upper and lower limb function.53 (c) The coverage provided for in this Code section shall inclu de no more than three54 orthotic devices or prosthetic devices per affected limb per co vered person during any55 three-year period. Such coverage shall include:56 (1) All materials and components for the use of the orthotic device or prosthetic device,57 including:58 (A) The orthosis or prosthesis;59 (B) Structural components such as the socket;60 (C) Suspension mechanisms such as the pin, lock, suction, and elevated vacuum;61 (D) Hip joint, knee joint, foot, alignable parts, and terminal device;62 (E) Connective components such as pads, bands, and cushions; and63 (F) Consumable items such as socks, sleeves, and liners;64 (2) Formulation of the device's design, fabrication, measurements and fittings;65 (3) Education and training on using and maintaining such device; and66 (4) The repair of such device and its components.67 (d)(1) The replacement of an orthotic device or prosthetic device and its materials and68 components when such device is less than three years old shall be medically necessary69 S. B. 265 - 3 - 25 LC 52 0771 if there is adequate documentation of a change in the physiolog ical condition of the70 covered person, an irreparable change in the condition of the d evice or any of its71 components, or the condition of the device or a component of the device requires repairs72 and the cost of such repairs would be more than 60 percent of the cost of the device.73 (2) A socket replacement shall be medically necessary if there is adequate documentation74 of a physiological need, including, but not limited to, a chang e in the residual limb, a75 functional need change, irreparable damage, or wear and tear due to excessive weight of76 a covered person or physical demands of an active covered person.77 (e) A health insurer shall not be required to replace or repai r an orthotic device or78 prosthetic device due to misuse, malicious damage, gross neglect, loss, or theft.79 (f) The coverage provided for in this Code section:80 (1) Shall be considered as habilitative or rehabilitative benefits for purposes of any state81 or federal requirements for coverage of essential health benefits;82 (2) Shall be comparable to coverage for other medical and surg ical benefits under the83 health benefit policy, including restorative internal devices;84 (3) May be subject to the same cost-sharing requirements that apply to other medical85 devices and services covered by the health benefit policy; provided, however, that such86 requirements shall not be solely applicable to such coverage; and87 (4) May be limited, or the cost-sharing requirements for such coverage may be altered88 for out-of-network providers; provided, however, that any limitations shall not be more89 restrictive than the restrictions and requirements applicable t o the out-of-network90 coverage for the policy's medical or surgical coverage.91 (g) Nothing in this Code section shall be construed to prohibit a health insurer from issuing92 or renewing a health benefit policy which provides benefits gre ater than the minimum93 benefits required under this Code section or from issuing or re newing a policy which94 provides benefits which are generally more favorable to the cov ered person than those95 required under this Code section.96 S. B. 265 - 4 - 25 LC 52 0771 (h) By July 1, 2032, the Commissioner shall submit a report to the House Committee on97 Insurance and the Senate Insurance and Labor Committee regardin g the implementation98 of the coverage required under this Code section. All health insurers issuing or renewing99 health benefit policies subject to the provisions of this Code section shall provide the100 department with all data requested by the department for inclus ion in such report,101 including, but limited to, the total number of claims submitted, the total number of claims102 paid, and the total amount of claims paid for the coverage provided for by this Code section103 for policy years from 2026 to 2030.104 (i) The Commissioner shall promulgate rules and regulations necessary to implement the105 provisions of this Code section."106 SECTION 2.107 This Act shall become effective upon its approval by the Governor or upon its becoming law108 without such approval, except that any coverage provided under a contract executed by this109 state shall be subject to appropriations.110 SECTION 3.111 All laws and parts of laws in conflict with this Act are repealed.112 S. B. 265 - 5 -