Insurance Fairness for Amputees Act - Amends the Employee Retirement Income Security Act of 1974 (ERISA) and the Public Health Service Act to require a group health plan that provides medical and surgical benefits and also provides benefits for prosthetics and custom orthotics to offer such prosthetics and custom orthotics in the same manner as applicable to medical and surgical benefits. Prohibits separate financial requirements or more restrictive treatment limitations. Requires a health plan that does not provide coverage for benefits outside of a network to ensure that such provider network is adequate to ensure enrollee access to prosthetic and custom orthotic devices and related services provided by appropriately credentialed practitioners and accredited suppliers.
Limits coverage for required benefits for prosthetics and custom orthotics to the most appropriate device or component that adequately meets the medical requirements of the patient. Requires benefits to include repair and replacement due to normal wear and tear, irreparable damage, a change in the condition of the patient, or as otherwise determined appropriate by the treating physician.
Prohibits any annual or lifetime dollar limitation on benefits for prosthetics and custom orthotics unless such limitation applies in the aggregate to all benefits.
Directs the Comptroller General (GAO) to study the effects of the implementation of this Act.
[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4175 Introduced in House (IH)]
112th CONGRESS
2d Session
H. R. 4175
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
prosthetics and custom orthotics and benefits for other medical and
surgical services.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 8, 2012
Mr. Dent (for himself and Mr. Andrews) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committee on Education and the Workforce, for a period
to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
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
prosthetics and custom orthotics and benefits for other medical and
surgical services.
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 ``Insurance Fairness for Amputees
Act''.
SEC. 2. FINDINGS AND PURPOSE.
(a) Findings.--Congress makes the following findings:
(1) There are more than 1,700,000 people in the United
States living with limb loss, many of whom are appropriate
candidates for prosthetic care. A comparable number experience
trauma, illness, or disability that results in musculoskeletal
or neuromuscular impairment of the limbs, back, and neck
requiring the use of orthotic care.
(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 and musculoskeletal
or neuromuscular injury.
(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 experiencing limb loss and limb dysfunction can
and want to regain their lives as productive members of
society.
(6) Prosthetic and orthotic care often enables amputees and
others with orthopedic impairments to continue working and
living productive lives.
(7) Insurance companies have begun to limit reimbursement
of prosthetic and custom orthotic care costs to unrealistic
levels and often restrict coverage over an individual's
lifetime, which shifts costs onto the Medicare and Medicaid
programs.
(8) Eighteen States have addressed this problem and have
prosthetic or orthotic parity legislation.
(9) Prosthetic and orthotic parity legislation has been
introduced and is being actively considered in 20 States.
(10) The States in which prosthetic or orthotic 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 or orthotic 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 prosthetics and custom orthotics are
offered by a group health insurance policy, then providing such
prosthetic coverage on par with other medical and surgical
benefits will not increase the incidence of amputations or the
number of individuals for which a prosthetic or custom orthotic
device would be medically necessary and appropriate.
(13) In States where prosthetic or orthotic parity
legislation has been enacted, amputees and others with
orthopedic impairments are able to return to productive lives,
State funds have been saved, and the health insurance industry
has continued to prosper.
(14) Prosthetic and orthotic devices and related services
allow people to return more quickly to their preexisting work.
(15) States have, and should continue to be permitted to,
create consumer protections that exceed the Federal floor of
protection provided for in this Act.
(b) Purpose.--It is the purpose of this Act to require that each
group health plan that provides medical and surgical benefits and also
provides coverage for prosthetics or custom orthotics (or both),
provide such coverage under terms and conditions that are no less
favorable than the terms and conditions under which medical and
surgical benefits are provided under such plan.
SEC. 3. PROSTHETICS AND CUSTOM ORTHOTICS 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. 716. PROSTHETICS AND CUSTOM ORTHOTICS 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 medical and surgical benefits and also provides benefits for
prosthetics or custom orthotics (as defined under paragraphs (1) and
(2) of subsection (e)) (or both)--
``(1) such benefits for prosthetics or custom orthotics (or
both) 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 prosthetics or custom orthotics (or
both) under the plan (or coverage) may not be subject to
separate financial requirements (as defined in subsection
(e)(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
(e)(3)) applicable to such benefits for prosthetics or custom
orthotics (or both) 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 medical or surgical benefits and
also provides benefits for prosthetics or custom orthotics (or
both), and that provides both in-network benefits for
prosthetics and custom orthotics and out-of-network benefits
for prosthetics and custom orthotics, 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) Patient Access.--A group health plan (or health insurance
coverage offered in connection with a group health plan) described in
subsection (a) that does not provide coverage for benefits outside of a
network shall ensure that such provider network is adequate to ensure
enrollee access to prosthetic and custom orthotic devices and related
services provided by appropriately credentialed practitioners and
accredited suppliers of prosthetics and custom orthotics.
``(d) 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 prosthetics or custom orthotics (or both) 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 medical and
surgical benefits provided under the plan (or coverage).
``(2) Limitation on mandated benefits.--Coverage for
required benefits for prosthetics and custom orthotics under
this section may be limited to coverage of the most appropriate
device or component model that 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
prosthetics and custom orthotics required under this section
shall include coverage for the repair or replacement of
prosthetics and custom orthotics, if the repair or replacement
is due to normal wear and tear, irreparable damage, a change in
the condition of the patient as determined by the treating
physician, or otherwise 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 prosthetics and
custom orthotics 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 prosthetics and custom orthotics.
``(e) Definitions.--In this section:
``(1) Prosthetics.--The term `prosthetics' 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) Custom orthotics.--The term `custom orthotics' means
the following:
``(A) Custom-fabricated orthotics and related
services, which include custom-fabricated devices that
are individually made for a specific patient, as well
as all services and supplies that are medically
necessary for the effective use of the orthotic device
and instructing the patient in the use of the device.
No other patient would be able to use this particular
orthosis. A custom-fabricated orthosis is a device
which is fabricated based on clinically derived and
rectified castings, tracings, measurements, or other
images (such as x-rays) of the body part. The
fabrication may involve using calculations, templates
and component parts. This process requires the use of
basic materials and involves substantial work such as
vacuum forming, cutting, bending, molding, sewing,
drilling and finishing prior to fitting on the patient.
Custom-fabricated devices may be furnished only by an
appropriately credentialed (certified or licensed)
practitioner and accredited supplier in Orthotics or
Prosthetics. Such devices and related services are
represented by the set of L-codes under the Healthcare
Common Procedure Coding System describing this care
listed on the date of enactment of this section in
Centers for Medicare & Medicaid Services Transmittal
656.
``(B) Custom-fitted high orthotics and related
services, which include prefabricated devices that are
manufactured with no specific patient in mind, but that
are appropriately sized, adapted, modified, and
configured (with the required tools and equipment) to a
specific patient in accordance with a prescription, and
which no other patient would be able to use, as well as
all services and supplies that are medically necessary
for the effective use of the orthotic device and
instructing the patient in the use of the device.
Custom-fitted high devices may be furnished only by an
appropriately credentialed (certified or licensed)
practitioner and accredited supplier in Orthotics or
Prosthetics. Such devices and related services are
represented by the existing set of L-codes under the
Healthcare Common Procedure Coding System describing
this care listed on the date of enactment of this
section in Centers for Medicare & Medicaid Services
Transmittal 656.
For purposes of subparagraphs (A) and (B), Centers for Medicare
& Medicaid Services Transmittal 656, upon modification or
reissuance by the Centers for Medicare & Medicaid Services to
reflect new code additions and coding changes for prosthetics
and custom orthotics, shall be the version of the Transmittal
used for purposes of such subparagraphs.
``(3) 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.
``(4) 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.
``(f) Differentiation From Durable Medical Equipment.--For purposes
of this section, prosthetics and custom orthotics shall be treated as
distinct from durable medical equipment.''.
(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 714 the
following:
``Sec. 716. Prosthetics and custom orthotics parity.''.
(b) PHSA.--Title XXVII of the Public Health Service Act is amended
by inserting after section 2728 of such Act (42 U.S.C. 300gg-28), as
redesignated by section 1001(2) of the Patient Protection and
Affordable Care Act (Public Law 111-148), the following:
``SEC. 2729. PROSTHETICS AND CUSTOM ORTHOTICS 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 medical and surgical benefits and also provides benefits for
prosthetics or custom orthotics (as defined under paragraphs (1) and
(2) of subsection (e)) (or both)--
``(1) such benefits for prosthetics or custom orthotics (or
both) 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 prosthetics or custom orthotics (or
both) under the plan (or coverage) may not be subject to
separate financial requirements (as defined in subsection
(e)(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
(e)(3)) applicable to such benefits for prosthetics or custom
orthotics (or both) 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 medical and surgical benefits and
also provides benefits for prosthetics or custom orthotics (or
both), and that provides both in-network and out-of-network
benefits for prosthetics or custom orthotics (or both), 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) Patient Access.--A group health plan (or health insurance
coverage offered in connection with a group health plan) described in
subsection (a) that does not provide coverage for benefits outside of a
network shall ensure that such provider network is adequate to ensure
enrollee access to prosthetic and custom orthotic devices and related
services provided by appropriately credentialed practitioners and
accredited suppliers of prosthetics and custom orthotics.
``(d) 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 prosthetics or custom orthotics (or both) 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 medical and
surgical benefits provided under the plan (or coverage).
``(2) Limitation on mandated benefits.--Coverage for
required benefits for prosthetics and custom orthotics under
this section may 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
prosthetics and custom orthotics required under this section
shall include coverage for the repair or replacement of
prosthetics and custom orthotics, if the repair or replacement
is due to normal wear and tear, irreparable damage, a change in
the condition of the patient as determined by the treating
physician, or otherwise 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 prosthetics and
custom orthotics 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 prosthetics and custom orthotics.
``(e) Definitions.--In this section:
``(1) Prosthetics.--The term `prosthetics' 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) Custom orthotics.--The term `custom orthotics' means
the following:
``(A) Custom-fabricated orthotics and related
services, which include custom-fabricated devices that
are individually made for a specific patient, as well
as all services and supplies that are medically
necessary for the effective use of the orthotic device
and instructing the patient in the use of the device.
No other patient would be able to use this particular
orthosis. A custom-fabricated orthosis is a device
which is fabricated based on clinically derived and
rectified castings, tracings, measurements, or other
images (such as x-rays) of the body part. The
fabrication may involve using calculations, templates
and component parts. This process requires the use of
basic materials and involves substantial work such as
vacuum forming, cutting, bending, molding, sewing,
drilling and finishing prior to fitting on the patient.
Custom-fabricated devices may be furnished only by an
appropriately credentialed (certified or licensed)
practitioner and accredited supplier in Orthotics or
Prosthetics. Such devices and related services are
represented by the set of L-codes under the Healthcare
Common Procedure Coding System describing this care
listed on the date of enactment of this section in
Centers for Medicare & Medicaid Services Transmittal
656.
``(B) Custom-fitted high orthotics and related
services, which include prefabricated devices that are
manufactured with no specific patient in mind, but that
are appropriately sized, adapted, modified, and
configured (with the required tools and equipment) to a
specific patient in accordance with a prescription, and
which no other patient would be able to use, as well as
all services and supplies that are medically necessary
for the effective use of the orthotic device and
instructing the patient in the use of the device.
Custom-fitted high devices may be furnished only by an
appropriately credentialed (certified or licensed)
practitioner and accredited supplier in Orthotics or
Prosthetics. Such devices and related services are
represented by the existing set of L-codes under the
Healthcare Common Procedure Coding System describing
this care listed on the date of enactment of this
section in Centers for Medicare & Medicaid Services
Transmittal 656.
For purposes of subparagraphs (A) and (B), Centers for Medicare
& Medicaid Services Transmittal 656, upon modification or
reissuance by the Centers for Medicare & Medicaid Services to
reflect new code additions and coding changes for prosthetics
and custom orthotics, shall be the version of the Transmittal
used for purposes of such subparagraphs.
``(3) 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.
``(4) 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.
``(f) Differentiation From Durable Medical Equipment.--For purposes
of this section, prosthetics and custom orthotics shall be treated as
distinct from durable medical equipment.''.
(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. UPDATING STANDARD DEFINITIONS TO INCLUDE PROSTHETICS AND CUSTOM
ORTHOTICS.
Section 2715(g)(3) of the Public Health Service Act (42 U.S.C.
300gg-15(g)(3)) is amended by inserting ``prosthetics, custom
orthotics,'' after ``emergency medical transportation,''.
SEC. 5. 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 group health plans (and health
insurance coverage offered in connection with such plans) 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 and custom orthotics on any additional cost or
savings to group health plans, on State prosthetics and custom
orthotics benefit 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.
SEC. 6. DEFINITIONS.
In this Act:
(1) Custom orthotics and prosthetics.--The terms ``custom
orthotics'' and ``prosthetics'' have the meanings given such
terms in section 716(e) of the Employee Retirement and Income
Security Act of 1974 (as added by section 3).
(2) Group health plan.--The term ``group health plan'' has
the meaning given such term in section 733(a) of such Act (29
U.S.C. 1191b(a)).
(3) Health insurance coverage.--The term ``health insurance
coverage'' has the meaning given such term in section 733(b)(1)
of such Act (29 U.S.C. 1191b(b)(1)).
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health, Employment, Labor, and Pensions.
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