SB 265: Insurance; health benefit policy coverage for medically necessary orthotic devices and prosthetic devices; require

Currently, Georgia law does not specifically require health insurance policies to cover orthotic devices (like braces) or prosthetic devices (like artificial limbs). This bill adds a new section to Georgia's insurance code requiring health benefit policies issued or renewed on or after January 1, 2026, to cover these devices when medically necessary for daily living, job duties, personal hygiene, or physical activity. The bill defines key terms like 'orthotic device' and 'prosthetic device,' excluding common over-the-counter items like elastic supports or canes. Coverage would include the devices themselves, their components, fitting, training, and repairs, but is capped at three devices per limb per person every three years. Insurers would not have to repair or replace devices damaged through misuse or theft. The Insurance Commissioner would report to legislative committees on implementation by July 1, 2032, and would write rules to carry out the law. The law takes effect once signed by the Governor, though coverage under state contracts depends on funding.

• Requires health benefit policies issued or renewed on or after January 1, 2026 to cover medically necessary orthotic and prosthetic devices.
• Limits covered devices to no more than three per affected limb per person in any three-year period.
• Defines when replacement of a device or its parts, such as a prosthetic socket, counts as medically necessary, including cases of physical change or repair costs exceeding 60 percent of the device's cost.
• Allows insurers to apply the same cost-sharing rules used for other medical devices, but bars cost-sharing rules that single out these devices alone.
• Requires the state Insurance Commissioner to report to House and Senate insurance committees by July 1, 2032 on claims data for these devices from 2026 to 2030.
• Directs the Commissioner to create rules and regulations to put the coverage requirement into practice.

People who use orthotic or prosthetic devices, including those with limb loss or musculoskeletal conditions; health insurers that sell health benefit policies in Georgia; and the state Insurance Commissioner's office, which must write rules and report on the program's results.

People needing braces, artificial limbs, or similar devices would gain a guaranteed insurance benefit covering the device, fittings, training, and repairs, potentially reducing out-of-pocket costs. Coverage limits and cost-sharing rules would still shape how much of the expense insurance actually offsets.

• Section 1 adds new Code Section 33-24-59.34 defining 'orthotic device,' 'prosthetic device,' 'medically necessary,' and related terms, excluding common over-the-counter items from coverage.
• Subsection (b) requires coverage for devices needed for daily living, job tasks, hygiene, or physical activities starting January 1, 2026.
• Subsection (c) caps coverage at three devices per limb per person every three years and lists covered components like sockets, joints, and consumable items such as liners and socks.
• Subsection (d) sets standards for when replacing a device or its parts within three years still counts as medically necessary, including physiological changes or high repair costs.
• Subsection (e) excludes coverage for repairs or replacement caused by misuse, malicious damage, gross neglect, loss, or theft.
• Subsection (f) requires this coverage be treated comparably to other medical and surgical benefits, with limited exceptions for out-of-network providers.
• Subsection (h) requires an Insurance Commissioner report to House and Senate insurance committees by July 1, 2032 using insurer-submitted claims data.
• Section 2 sets the effective date as upon the Governor's signature, with state contract coverage subject to available funding.

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

• Shawn Still (R, SD-48)Primary sponsor
• Ben Watson (R, SD-1)

• health insurance
• prosthetic devices
• orthotic devices
• disability access
• insurance regulation