I

106TH CONGRESS

2D SESSION H. R. 5156

To amend title XVIII of the Social Security Act to establish standards

for payment under the Medicare Program for certain orthotic, prosthetic,

and pedorthic devices.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 12, 2000

Mrs. MCCARTHY of New York introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committee

on Ways and Means, 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 title XVIII of the Social Security Act to establish

standards for payment under the Medicare Program for

certain orthotic, prosthetic, and pedorthic devices.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. STANDARDS REGARDING PAYMENT FOR CER4 TAIN ORTHOTICS, PROSTHETICS, AND

5 PEDORTHICS.

6 (a) STANDARDS.—Section 1834(h)(1) of the Social

7 Security Act (42 U.S.C. 1395m(h)(1)) is amended by add8 ing at the end the following new subparagraph
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1 ‘‘(F) ESTABLISHMENT OF STANDARDS FOR

2 CERTAIN ITEMS.—

3 ‘‘(i) IN GENERAL.—No payment shall

4 be made for an applicable item unless the

5 item is provided by a qualified practitioner

6 or a qualified supplier under the system es7 tablished by the Secretary under clause

8 (iii). For purposes of the preceding sen9 tence, if a qualified practitioner or a quali10 fied supplier contracts with an entity to

11 provide an applicable item, then no pay12 ment shall be made for such item unless

13 the entity is also a qualified supplier.

14 ‘‘(ii) DEFINITIONS.—In this subpara15 graph:

16 ‘‘(I) APPLICABLE ITEM.—The

17 term ‘applicable item’ means

18 orthotics, prosthetics, and pedorthics

19 that require education, training, and

20 experience to dispense such item as a

21 part of a treatment plan.

22 ‘‘(II) QUALIFIED PRACTI23 TIONER.—The term ‘qualified practi24 tioner’ means a physician or health

25 care professional who—
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1 ‘‘(aa) is specifically trained

2 and educated to provide or man3 age the provision of custom-de4 signed, fabricated, modified, and

5 fitted orthotics, prosthetics, and

6 pedorthics, and is certified by the

7 American Board for Certification

8 in Orthotics and Prosthetics,

9 Inc., to dispense orthotics, pros10 thetics, or pedorthic devices, is

11 specifically trained and educated

12 to provide or manage the provi13 sion of custom-designed, fab14 ricated, modified, and fitted

15 pedorthics and is certified by the

16 Board for Certification in

17 Pedorthics to dispense pedorthic

18 devices, or is credentialed and

19 approved by a program that the

20 Secretary determines, in con21 sultation with appropriate ex22 perts in orthotics, prosthetics,

23 and pedorthics, has training and

24 education standards that are nec-
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1 essary to provide applicable

2 items;

3 ‘‘(bb) is licensed in

4 orthotics, prosthetics, or

5 pedorthics by the State in which

6 the applicable item is supplied; or

7 ‘‘(cc) has completed at least

8 10 years of practice in the provi9 sion of applicable items.

10 ‘‘(III) QUALIFIED SUPPLIER.—

11 The term ‘qualified supplier’ means

12 any entity that is—

13 ‘‘(aa) accredited by the

14 American Board for Certification

15 in Orthotics and Prosthetics,

16 Inc.;

17 ‘‘(bb) accredited by the

18 Board for Certification in

19 Pedorthics, Inc., to dispense

20 pedorthic devices; or

21 ‘‘(cc) accredited and ap22 proved by a program that the

23 Secretary determines has accredi24 tation and approval standards
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1 that are essentially equivalent to

2 those of such Boards.

3 ‘‘(iii) SYSTEM.—The Secretary, in

4 consultation with appropriate experts in

5 orthotics, prosthetics, and pedorthics, shall

6 establish a system under which the Sec7 retary shall—

8 ‘‘(I) determine which items are

9 applicable items and formulate a list

10 of such items;

11 ‘‘(II) review the applicable items

12 billed under the coding system estab13 lished under this title; and

14 ‘‘(III) limit payment for applica15 ble items pursuant to clause (i).’’.

16 (b) REVISION OF DEFINITION OF ORTHOTICS.—Sec17 tion 1861(s)(9) of the Social Security Act (42 U.S.C.

18 1395x(s)(9)) is amended by inserting ‘‘(including such

19 braces that are used in conjunction with, or as components

20 of, other medical or nonmedical equipment when provided

21 by a qualified practitioner (as defined in subclause (II)

22 of section 1834(h)(1)(F)(ii)) or a qualified supplier (as de23 fined in subclause (III) of such section)’’ after ‘‘braces’’.

24 (c) DEFINITION OF PEDORTHIC DEVICES.—
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1 (1) IN GENERAL.—Section 1861(s) of the So2 cial Security Act (42 U.S.C. 1395x(s)) is amended—

3 (A) by redesignating paragraphs (16) and

4 (17) as paragraphs (17) and (18), respectively;

5 (B) by striking ‘‘and’’ at the end of para6 graph (14);

7 (C) by striking the period at the end of

8 paragraph (15) and inserting ‘‘; and’’; and

9 (D) by inserting after paragraph (15) the

10 following new paragraph:

11 ‘‘(16)(A) pedorthic devices consisting of thera12 peutic shoes, shoe modifications made for thera13 peutic purposes, partial foot prostheses, and foot

14 orthoses for use from the ankle and below, but not

15 including non-therapeutic, accommodative inlays and

16 non-therapeutic accommodative footwear (regardless

17 of method of manufacture) or prefabricated foot care

18 products; and

19 ‘‘(B) in subparagraph (A)—

20 ‘‘(i) a pedorthic device is therapeutic if the

21 device addresses a medical condition and is pre22 scribed by a physician or practitioner; and

23 ‘‘(ii) an inlay or footwear is accommodative

24 is an inlay or footwear that is designed with a
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1 primary goal of conforming to an individual’s

2 anatomy.’’.

3 (2) CONFORMING AMENDMENTS.—Sections

4 1864(a), 1902(a)(9)(C), and 1915(a)(1)(B)(ii)(I) of

5 such Act (42 U.S.C. 1395aa(a), 1396a(a)(9)(C), and

6 1396n(a)(1)(B)(ii)(I)) are each amended by striking

7 ‘‘paragraphs (16) and (17)’’ each place it appears

8 and inserting ‘‘paragraphs (17) and (18)’’.

Æ