I 

113TH CONGRESS 

1ST SESSION H. R. 3020 

To amend the Employee Retirement Income Security Act of 1974, the Public 

Health Service Act, and the Internal Revenue Code of 1986 to provide 

parity under group and individual health plans and group and individual 

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 

AUGUST 2, 2013 

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 Committees on Education and the Workforce and 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 the Employee Retirement Income Security Act 

of 1974, the Public Health Service Act, and the Internal 

Revenue Code of 1986 to provide parity under group 

and individual health plans and group and individual 

health insurance coverage for the provision of benefits 

for prosthetics and custom orthotics and benefits for 

other medical and surgical services. 

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


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Insurance Fairness 

3 for Amputees Act’’. 

4 SEC. 2. FINDINGS AND PURPOSE. 

5 (a) FINDINGS.—Congress makes the following find6 ings: 

7 (1) There are more than 1,700,000 people in 

8 the United States living with limb loss, many of 

9 whom are appropriate candidates for prosthetic care. 

10 A comparable number experience trauma, illness, or 

11 disability that results in musculoskeletal or neuro12 muscular impairment of the limbs, back, and neck 

13 requiring the use of orthotic care. 

14 (2) Every year, there are more than 130,000 

15 people in the United States who undergo amputation 

16 procedures. 

17 (3) In addition, United States military per18 sonnel serving in Iraq and Afghanistan and around 

19 the world have sustained traumatic injuries resulting 

20 in amputation and musculoskeletal or neuromuscular 

21 injury. 

22 (4) The number of amputations in the United 

23 States is projected to increase in the years ahead 

24 due to the rising incidence of diabetes and other 

25 chronic illness. 


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1 (5) Those experiencing limb loss and limb dys2 function can and want to regain their lives as pro3 ductive members of society, and prosthetic and 

4 orthotic care often enables amputees and others with 

5 orthopedic impairments to continue working and liv6 ing productive lives. 

7 (6) Insurance companies often restrict coverage 

8 for prosthetic and orthotic devices and related serv9 ices over an individual’s lifetime, which shifts costs 

10 onto individuals and consequently to the Medicare 

11 and Medicaid programs. 

12 (7) Twenty States have addressed this problem 

13 and have prosthetic or orthotic parity legislation, 

14 which also is being considered actively in other 

15 States. 

16 (8) The States in which prosthetic or orthotic 

17 fairness in coverage laws have been enacted have 

18 found there to be minimal or no increases in insur19 ance premiums and have reduced Medicare and 

20 Medicaid costs. 

21 (9) Coverage of orthotic and prosthetic devices 

22 and related services is only appropriate for individ23 uals missing a limb or having an orthopedic condi24 tion in need of treatment. Therefore, a fixed popuVerDate Mar 15 2010 00:47 Aug 10, 2013 Jkt 029200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\H3020.IH H3020

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1 lation of individuals are candidates for these devices 

2 and related services. 

3 (10) Appropriate and timely treatment involv4 ing prosthetic and orthotic devices and related serv5 ices allow people to regain health function, pre6 existing work, and independent living. 

7 (11) Prosthetic and orthotic devices and related 

8 services are a distinct and separate benefit from the 

9 durable medical equipment benefit, but this distinc10 tion often is not recognized as insurers typically 

11 combine these benefits under a combined limit. 

12 (12) The Patient Protection and Affordable 

13 Care Act (Public Law 111–148) and the Health 

14 Care and Education Reconciliation Act (Public Law 

15 111–152), include rehabilitative and habilitative 

16 services as an essential health benefit, which legisla17 tive history shows is intended to cover prosthetic and 

18 orthotic devices and related services. 

19 (13) The Institute of Medicine concluded that 

20 prosthetic and orthotic devices and related services 

21 are covered under a typical employer plan. 

22 (14) However, while lifetime and annual dollar 

23 limitations on essential health benefits are prohibited 

24 under the Patient Protection and Affordable Care 

25 Act (Public Law 111–148) and the Health Care and 


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1 Education Reconciliation Act (Public Law 111–152), 

2 other techniques to minimize or eliminate coverage 

3 continue to be used across the country and are deny4 ing individuals access to medically necessary pros5 thetic and orthotic devices and related services. 

6 (b) PURPOSE.—It is the purpose of this Act to re7 quire that each group and individual health plan and indi8 vidual and group health insurance coverage that provides 

9 medical and surgical benefits and also provides coverage 

10 for prosthetics or custom orthotics (or both), provide such 

11 coverage under terms and conditions that are no less fa12 vorable than the terms and conditions under which med13 ical and surgical benefits are provided under such plan. 

14 SEC. 3. PROSTHETICS AND CUSTOM ORTHOTICS FAIRNESS 

15 IN COVERAGE. 

16 (a) ERISA.— 

17 (1) IN GENERAL.—Subpart B of part 7 of sub18 title B of title I of the Employee Retirement Income 

19 Security Act of 1974 (29 U.S.C. 1185 et seq.) is 

20 amended by adding at the end the following: 

21 ‘‘SEC. 716. PROSTHETICS AND CUSTOM ORTHOTICS FAIR22 NESS IN COVERAGE. 

23 ‘‘(a) IN GENERAL.—In the case of a group health 

24 plan (or health insurance coverage offered in connection 

25 with a group health plan) that provides medical and surVerDate Mar 15 2010 00:47 Aug 10, 2013 Jkt 029200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\H3020.IH H3020

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1 gical benefits and also provides benefits for prosthetics or 

2 custom orthotics (as defined under paragraphs (1) and (2) 

3 of subsection (e)) (or both)— 

4 ‘‘(1) such benefits for prosthetics or custom 

5 orthotics (or both) under the plan (or coverage) shall 

6 be provided under terms and conditions that are no 

7 less favorable than the terms and conditions applica8 ble to substantially all medical and surgical benefits 

9 provided under the plan (or coverage); 

10 ‘‘(2) such benefits for prosthetics or custom 

11 orthotics (or both) under the plan (or coverage) may 

12 not be subject to separate financial requirements (as 

13 defined in subsection (d)(3)) that are applicable only 

14 with respect to such benefits, and any financial re15 quirements applicable to such benefits shall be no 

16 more restrictive than the financial requirements ap17 plicable to substantially all medical and surgical ben18 efits provided under the plan (or coverage); and 

19 ‘‘(3) any treatment limitations (as defined in 

20 subsection (d)(4)) applicable to such benefits for 

21 prosthetics or custom orthotics (or both) under the 

22 plan (or coverage) may not be more restrictive than 

23 the treatment limitations applicable to substantially 

24 all medical and surgical benefits provided under the 

25 plan (or coverage). 


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1 ‘‘(b) PATIENT ACCESS.—A group health plan (or 

2 health insurance coverage offered in connection with a 

3 group health plan) described in subsection (a) that does 

4 not provide coverage for benefits outside of a network shall 

5 ensure that such provider network is adequate to ensure 

6 enrollee access to prosthetic and custom orthotic devices 

7 and related services provided by appropriately credentialed 

8 practitioners and accredited suppliers of prosthetics and 

9 custom orthotics. 

10 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

11 ‘‘(1) PRIOR AUTHORIZATION.—In the case of a 

12 group health plan (or health insurance coverage of13 fered in connection with a group health plan) that 

14 requires, as a condition of coverage or payment for 

15 prosthetics or custom orthotics (or both) under the 

16 plan (or coverage), prior authorization, such prior 

17 authorization must be required in the same manner 

18 as prior authorization is required by the plan (or 

19 coverage) as a condition of coverage or payment for 

20 all similar medical and surgical benefits provided 

21 under the plan (or coverage). 

22 ‘‘(2) LIMITATION ON BENEFITS.—Coverage for 

23 required benefits for prosthetics and custom 

24 orthotics under this section may be limited to cov25 erage of the most appropriate device or component 


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1 model that meets the medical requirements of the 

2 patient, as determined by the treating physician of 

3 the patient involved. 

4 ‘‘(3) COVERAGE FOR REPAIR OR REPLACE5 MENT.—Benefits for prosthetics and custom 

6 orthotics required under this section shall include 

7 coverage for the repair or replacement of prosthetics 

8 and custom orthotics, if the repair or replacement is 

9 due to normal wear and tear, irreparable damage, a 

10 change in the condition of the patient as determined 

11 by the treating physician, or otherwise determined 

12 appropriate by the treating physician of the patient 

13 involved. 

14 ‘‘(d) DEFINITIONS.—In this section: 

15 ‘‘(1) PROSTHETICS.—The term ‘prosthetics’ 

16 means those devices and components that may be 

17 used to replace, in whole or in part, an arm or leg, 

18 as well as the services required to do so and includes 

19 external breast prostheses incident to mastectomy 

20 resulting from breast cancer. 

21 ‘‘(2) CUSTOM ORTHOTICS.—The term ‘custom 

22 orthotics’ means the following: 

23 ‘‘(A) Custom-fabricated orthotics and re24 lated services, which include custom-fabricated 

25 devices that are individually made for a specific 


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1 patient, as well as all services and supplies that 

2 are medically necessary for the effective use of 

3 the orthotic device and instructing the patient 

4 in the use of the device. No other patient would 

5 be able to use this particular orthosis. A cus6 tom-fabricated orthosis is a device which is fab7 ricated based on clinically derived and rectified 

8 castings, tracings, measurements, or other im9 ages (such as x-rays) of the body part. The fab10 rication may involve using calculations, tem11 plates and component parts. This process re12 quires the use of basic materials and involves 

13 substantial work such as vacuum forming, cut14 ting, bending, molding, sewing, drilling and fin15 ishing prior to fitting on the patient. Custom16 fabricated devices may be furnished only by an 

17 appropriately credentialed (certified or licensed) 

18 practitioner and accredited supplier in Orthotics 

19 or Prosthetics. Such devices and related serv20 ices are represented by the set of L-codes under 

21 the Healthcare Common Procedure Coding Sys22 tem describing this care listed on the date of 

23 enactment of this section in Centers for Medi24 care & Medicaid Services Transmittal 656. 


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1 ‘‘(B) Custom-fitted high orthotics and re2 lated services, which include prefabricated de3 vices that are manufactured with no specific pa4 tient in mind, but that are appropriately sized, 

5 adapted, modified, and configured (with the re6 quired tools and equipment) to a specific pa7 tient in accordance with a prescription, and 

8 which no other patient would be able to use, as 

9 well as all services and supplies that are medi10 cally necessary for the effective use of the 

11 orthotic device and instructing the patient in 

12 the use of the device. Custom-fitted high devices 

13 may be furnished only by an appropriately 

14 credentialed (certified or licensed) practitioner 

15 and accredited supplier in Orthotics or Pros16 thetics. Such devices and related services are 

17 represented by the existing set of L-codes under 

18 the Healthcare Common Procedure Coding Sys19 tem describing this care listed on the date of 

20 enactment of this section in Centers for Medi21 care & Medicaid Services Transmittal 656. 

22 For purposes of subparagraphs (A) and (B), Centers 

23 for Medicare & Medicaid Services Transmittal 656, 

24 upon modification or reissuance by the Centers for 

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1 ditions and coding changes for prosthetics and cus2 tom orthotics, shall be the version of the Transmittal 

3 used for purposes of such subparagraphs. 

4 ‘‘(3) FINANCIAL REQUIREMENTS.—The term 

5 ‘financial requirements’ includes deductibles, coin6 surance, co-payments, other cost sharing, and limita7 tions on the total amount that may be paid by a 

8 participant or beneficiary with respect to benefits 

9 under the plan or health insurance coverage. 

10 ‘‘(4) TREATMENT LIMITATIONS.—The term 

11 ‘treatment limitations’ includes limits on the fre12 quency of treatment, number of visits, specific pre13 scribed components, limits that are more broadly ap14 plicable to durable medical equipment, or other simi15 lar limits on the amount, duration, or scope of treat16 ment. 

17 ‘‘(e) DIFFERENTIATION FROM DURABLE MEDICAL

18 EQUIPMENT.—For purposes of this section, prosthetics 

19 and custom orthotics shall be treated as distinct from du20 rable medical equipment.’’. 

21 (2) CLERICAL AMENDMENT.—The table of con22 tents in section 1 of the Employee Retirement In23 come Security Act of 1974 is amended by inserting 

24 after the item relating to section 714 the following: 

‘‘Sec. 715. Additional market reforms. 

‘‘Sec. 716. Prosthetics and custom orthotics parity.’’. 


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1 (b) PHSA.— 

2 (1) IN GENERAL.—Title XXVII of the Public 

3 Health Service Act is amended by inserting after 

4 section 2728 of such Act (42 U.S.C. 300gg–28), as 

5 redesignated by section 1001(2) of the Patient Pro6 tection and Affordable Care Act (Public Law 111– 

7 148), the following: 

8 ‘‘SEC. 2729. PROSTHETICS AND CUSTOM ORTHOTICS PAR9 ITY. 

10 ‘‘(a) IN GENERAL.—In the case of a group health 

11 plan, or a health insurance issuer offering group or indi12 vidual health insurance coverage, that provides medical 

13 and surgical benefits and also provides benefits for pros14 thetics or custom orthotics (as defined under paragraphs 

15 (1) and (2) of subsection (e)) (or both)— 

16 ‘‘(1) such benefits for prosthetics or custom 

17 orthotics (or both) under the plan or coverage shall 

18 be provided under terms and conditions that are no 

19 less favorable than the terms and conditions applica20 ble to substantially all medical and surgical benefits 

21 provided under the plan or coverage; 

22 ‘‘(2) such benefits for prosthetics or custom 

23 orthotics (or both) under the plan or coverage may 

24 not be subject to separate financial requirements (as 

25 defined in subsection (e)(2)) that are applicable only 


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1 with respect to such benefits, and any financial re2 quirements applicable to such benefits shall be no 

3 more restrictive than the financial requirements ap4 plicable to substantially all medical and surgical ben5 efits provided under the plan or coverage; and 

6 ‘‘(3) any treatment limitations (as defined in 

7 subsection (e)(3)) applicable to such benefits for 

8 prosthetics or custom orthotics (or both) under the 

9 plan or coverage may not be more restrictive than 

10 the treatment limitations applicable to substantially 

11 all medical and surgical benefits provided under the 

12 plan or coverage. 

13 ‘‘(b) PATIENT ACCESS.—A group health plan, or 

14 health insurance issuer offering group or individual health 

15 insurance coverage, described in subsection (a) that does 

16 not provide coverage for benefits outside of a network shall 

17 ensure that such provider network is adequate to ensure 

18 enrollee access to prosthetic and custom orthotic devices 

19 and related services provided by appropriately credentialed 

20 practitioners and accredited suppliers of prosthetics and 

21 custom orthotics. 

22 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

23 ‘‘(1) PRIOR AUTHORIZATION.—In the case of a 

24 group health plan, or health insurance issuer offer25 ing group or individual health insurance coverage, 


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1 that requires, as a condition of coverage or payment 

2 for prosthetics or custom orthotics (or both) under 

3 the plan or coverage, prior authorization, such prior 

4 authorization must be required in the same manner 

5 as prior authorization is required by the plan or cov6 erage as a condition of coverage or payment for all 

7 similar medical and surgical benefits provided under 

8 the plan or coverage. 

9 ‘‘(2) LIMITATION ON BENEFITS.—Coverage for 

10 required benefits for prosthetics and custom 

11 orthotics under this section may be limited to cov12 erage of the most appropriate device or component 

13 model that adequately meets the medical require14 ments of the patient, as determined by the treating 

15 physician of the patient involved. 

16 ‘‘(3) COVERAGE FOR REPAIR OR REPLACE17 MENT.—Benefits for prosthetics and custom 

18 orthotics required under this section shall include 

19 coverage for the repair or replacement of prosthetics 

20 and custom orthotics, if the repair or replacement is 

21 due to normal wear and tear, irreparable damage, a 

22 change in the condition of the patient as determined 

23 by the treating physician, or otherwise determined 

24 appropriate by the treating physician of the patient 

25 involved. 


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1 ‘‘(d) DEFINITIONS.—In this section: 

2 ‘‘(1) PROSTHETICS.—The term ‘prosthetics’ 

3 means those devices and components that may be 

4 used to replace, in whole or in part, an arm or leg, 

5 as well as the services required to do so and includes 

6 external breast prostheses incident to mastectomy 

7 resulting from breast cancer. 

8 ‘‘(2) CUSTOM ORTHOTICS.—The term ‘custom 

9 orthotics’ means the following: 

10 ‘‘(A) Custom-fabricated orthotics and re11 lated services, which include custom-fabricated 

12 devices that are individually made for a specific 

13 patient, as well as all services and supplies that 

14 are medically necessary for the effective use of 

15 the orthotic device and instructing the patient 

16 in the use of the device. No other patient would 

17 be able to use this particular orthosis. A cus18 tom-fabricated orthosis is a device which is fab19 ricated based on clinically derived and rectified 

20 castings, tracings, measurements, or other im21 ages (such as x-rays) of the body part. The fab22 rication may involve using calculations, tem23 plates and component parts. This process re24 quires the use of basic materials and involves 

25 substantial work such as vacuum forming, cutVerDate Mar 15 2010 00:47 Aug 10, 2013 Jkt 029200 PO 00000 Frm 00015 Fmt 6652 Sfmt 6201 E:\BILLS\H3020.IH H3020

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1 ting, bending, molding, sewing, drilling and fin2 ishing prior to fitting on the patient. Custom3 fabricated devices may be furnished only by an 

4 appropriately credentialed (certified or licensed) 

5 practitioner and accredited supplier in Orthotics 

6 or Prosthetics. Such devices and related serv7 ices are represented by the set of L-codes under 

8 the Healthcare Common Procedure Coding Sys9 tem describing this care listed on the date of 

10 enactment of this section in Centers for Medi11 care & Medicaid Services Transmittal 656. 

12 ‘‘(B) Custom-fitted high orthotics and re13 lated services, which include prefabricated de14 vices that are manufactured with no specific pa15 tient in mind, but that are appropriately sized, 

16 adapted, modified, and configured (with the re17 quired tools and equipment) to a specific pa18 tient in accordance with a prescription, and 

19 which no other patient would be able to use, as 

20 well as all services and supplies that are medi21 cally necessary for the effective use of the 

22 orthotic device and instructing the patient in 

23 the use of the device. Custom-fitted high devices 

24 may be furnished only by an appropriately 

25 credentialed (certified or licensed) practitioner 


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1 and accredited supplier in Orthotics or Pros2 thetics. Such devices and related services are 

3 represented by the existing set of L-codes under 

4 the Healthcare Common Procedure Coding Sys5 tem describing this care listed on the date of 

6 enactment of this section in Centers for Medi7 care & Medicaid Services Transmittal 656. 

8 For purposes of subparagraphs (A) and (B), Centers 

9 for Medicare & Medicaid Services Transmittal 656, 

10 upon modification or reissuance by the Centers for 

11 Medicare & Medicaid Services to reflect new code ad12 ditions and coding changes for prosthetics and cus13 tom orthotics, shall be the version of the Transmittal 

14 used for purposes of such subparagraphs. 

15 ‘‘(3) FINANCIAL REQUIREMENTS.—The term 

16 ‘financial requirements’ includes deductibles, coin17 surance, co-payments, other cost sharing, and limita18 tions on the total amount that may be paid by a 

19 participant or beneficiary with respect to benefits 

20 under the plan or health insurance coverage. 

21 ‘‘(4) TREATMENT LIMITATIONS.—The term 

22 ‘treatment limitations’ includes limits on the fre23 quency of treatment, number of visits, specific pre24 scribed components, and limits that are more broad25 ly applicable to durable medical equipment, or other 


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1 similar limits on the amount, duration, or scope of 

2 treatment. 

3 ‘‘(e) DIFFERENTIATION FROM DURABLE MEDICAL

4 EQUIPMENT.—For purposes of this section, prosthetics 

5 and custom orthotics shall be treated as distinct from du6 rable medical equipment.’’. 

7 (2) APPLICATION TO INDIVIDUAL HEALTH IN8 SURANCE COVERAGE BEFORE 2014.—For purposes of 

9 applying section 2729 of the Public Health Service 

10 Act, as inserted by paragraph (1), to individual 

11 health insurance coverage before 2014, the provi12 sions of such section shall be treated as also in13 cluded under part B of title XXVII of the Public 

14 Health Service Act. 

15 (c) INTERNAL REVENUE CODE.—Subchapter B of 

16 chapter 100 of subtitle K of the Internal Revenue Code 

17 of 1986 is amended by adding after section 9813 the fol18 lowing: 

19 ‘‘SEC. 9814. PROSTHETICS AND CUSTOM ORTHOTICS FAIR20 NESS IN COVERAGE. 

21 ‘‘(a) IN GENERAL.—In the case of a group health 

22 plan (or health insurance coverage offered in connection 

23 with a group health plan) that provides medical and sur24 gical benefits and also provides benefits for prosthetics or 


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1 custom orthotics (as defined under paragraphs (1) and (2) 

2 of subsection (e)) (or both)— 

3 ‘‘(1) such benefits for prosthetics or custom 

4 orthotics (or both) under the plan (or coverage) shall 

5 be provided under terms and conditions that are no 

6 less favorable than the terms and conditions applica7 ble to substantially all medical and surgical benefits 

8 provided under the plan (or coverage); 

9 ‘‘(2) such benefits for prosthetics or custom 

10 orthotics (or both) under the plan (or coverage) may 

11 not be subject to separate financial requirements (as 

12 defined in subsection (e)(2)) that are applicable only 

13 with respect to such benefits, and any financial re14 quirements applicable to such benefits shall be no 

15 more restrictive than the financial requirements ap16 plicable to substantially all medical and surgical ben17 efits provided under the plan (or coverage); and 

18 ‘‘(3) any treatment limitations (as defined in 

19 subsection (e)(3)) applicable to such benefits for 

20 prosthetics or custom orthotics (or both) under the 

21 plan (or coverage) may not be more restrictive than 

22 the treatment limitations applicable to substantially 

23 all medical and surgical benefits provided under the 

24 plan (or coverage). 


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1 ‘‘(b) PATIENT ACCESS.—A group health plan (or 

2 health insurance coverage offered in connection with a 

3 group health plan) described in subsection (a) that does 

4 not provide coverage for benefits outside of a network shall 

5 ensure that such provider network is adequate to ensure 

6 enrollee access to prosthetic and custom orthotic devices 

7 and related services provided by appropriately credentialed 

8 practitioners and accredited suppliers of prosthetics and 

9 custom orthotics. 

10 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

11 ‘‘(1) PRIOR AUTHORIZATION.—In the case of a 

12 group health plan (or health insurance coverage of13 fered in connection with a group health plan) that 

14 requires, as a condition of coverage or payment for 

15 prosthetics or custom orthotics (or both) under the 

16 plan (or coverage), prior authorization, such prior 

17 authorization must be required in the same manner 

18 as prior authorization is required by the plan (or 

19 coverage) as a condition of coverage or payment for 

20 all similar medical and surgical benefits provided 

21 under the plan (or coverage). 

22 ‘‘(2) LIMITATION ON BENEFITS.—Coverage for 

23 required benefits for prosthetics and custom 

24 orthotics under this section may be limited to cov25 erage of the most appropriate device or component 


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1 model that meets the medical requirements of the 

2 patient, as determined by the treating physician of 

3 the patient involved. 

4 ‘‘(3) COVERAGE FOR REPAIR OR REPLACE5 MENT.—Benefits for prosthetics and custom 

6 orthotics required under this section shall include 

7 coverage for the repair or replacement of prosthetics 

8 and custom orthotics, if the repair or replacement is 

9 due to normal wear and tear, irreparable damage, a 

10 change in the condition of the patient as determined 

11 by the treating physician, or otherwise determined 

12 appropriate by the treating physician of the patient 

13 involved. 

14 ‘‘(4) ASSISTANCE TO ENROLLEES.—The Sec15 retary of the Treasury, in consultation with the Sec16 retary of Health and Human Services, shall provide 

17 assistance to enrollees under plans or coverage to 

18 which the amendment made by section 3 apply with 

19 any questions or problems with respect to compli20 ance with the requirements of such amendment. 

21 ‘‘(5) AUDITS.—The Secretary of the Treasury, 

22 in consultation with the Secretary of Health and 

23 Human Services, shall provide for the conduct of 

24 random audits of group health plans (and health in25 surance coverage offered in connection with such 


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1 plans) to ensure that such plans (or coverage) are in 

2 compliance with the amendments made by section 

3 (3). 

4 ‘‘(d) DEFINITIONS.—In this section: 

5 ‘‘(1) PROSTHETICS.—The term ‘prosthetics’ 

6 means those devices and components that may be 

7 used to replace, in whole or in part, an arm or leg, 

8 as well as the services required to do so and includes 

9 external breast prostheses incident to mastectomy 

10 resulting from breast cancer. 

11 ‘‘(2) CUSTOM ORTHOTICS.—The term ‘custom 

12 orthotics’ means the following: 

13 ‘‘(A) Custom-fabricated orthotics and re14 lated services, which include custom-fabricated 

15 devices that are individually made for a specific 

16 patient, as well as all services and supplies that 

17 are medically necessary for the effective use of 

18 the orthotic device and instructing the patient 

19 in the use of the device. No other patient would 

20 be able to use this particular orthosis. A cus21 tom-fabricated orthosis is a device which is fab22 ricated based on clinically derived and rectified 

23 castings, tracings, measurements, or other im24 ages (such as x-rays) of the body part. The fab25 rication may involve using calculations, temVerDate Mar 15 2010 00:47 Aug 10, 2013 Jkt 029200 PO 00000 Frm 00022 Fmt 6652 Sfmt 6201 E:\BILLS\H3020.IH H3020

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1 plates and component parts. This process re2 quires the use of basic materials and involves 

3 substantial work such as vacuum forming, cut4 ting, bending, molding, sewing, drilling and fin5 ishing prior to fitting on the patient. Custom6 fabricated devices may be furnished only by an 

7 appropriately credentialed (certified or licensed) 

8 practitioner and accredited supplier in Orthotics 

9 or Prosthetics. Such devices and related serv10 ices are represented by the set of L-codes under 

11 the Healthcare Common Procedure Coding Sys12 tem describing this care listed on the date of 

13 enactment of this section in Centers for Medi14 care & Medicaid Services Transmittal 656. 

15 ‘‘(B) Custom-fitted high orthotics and re16 lated services, which include prefabricated de17 vices that are manufactured with no specific pa18 tient in mind, but that are appropriately sized, 

19 adapted, modified, and configured (with the re20 quired tools and equipment) to a specific pa21 tient in accordance with a prescription, and 

22 which no other patient would be able to use, as 

23 well as all services and supplies that are medi24 cally necessary for the effective use of the 

25 orthotic device and instructing the patient in 


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1 the use of the device. Custom-fitted high devices 

2 may be furnished only by an appropriately 

3 credentialed (certified or licensed) practitioner 

4 and accredited supplier in Orthotics or Pros5 thetics. Such devices and related services are 

6 represented by the existing set of L-codes under 

7 the Healthcare Common Procedure Coding Sys8 tem describing this care listed on the date of 

9 enactment of this section in Centers for Medi10 care & Medicaid Services Transmittal 656. 

11 For purposes of subparagraphs (A) and (B), Centers 

12 for Medicare & Medicaid Services Transmittal 656, 

13 upon modification or reissuance by the Centers for 

14 Medicare & Medicaid Services to reflect new code ad15 ditions and coding changes for prosthetics and cus16 tom orthotics, shall be the version of the Transmittal 

17 used for purposes of such subparagraphs. 

18 ‘‘(3) FINANCIAL REQUIREMENTS.—The term 

19 ‘financial requirements’ includes deductibles, coin20 surance, co-payments, other cost sharing, and limita21 tions on the total amount that may be paid by a 

22 participant or beneficiary with respect to benefits 

23 under the plan or health insurance coverage. 

24 ‘‘(4) TREATMENT LIMITATIONS.—The term 

25 ‘treatment limitations’ includes limits on the freVerDate Mar 15 2010 00:47 Aug 10, 2013 Jkt 029200 PO 00000 Frm 00024 Fmt 6652 Sfmt 6201 E:\BILLS\H3020.IH H3020

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1 quency of treatment, number of visits, specific pre2 scribed components, or other similar limits on the 

3 scope or duration of treatment. 

4 ‘‘(e) DIFFERENTIATION FROM DURABLE MEDICAL

5 EQUIPMENT.—For purposes of this section, prosthetics 

6 and custom orthotics shall be treated as distinct from du7 rable medical equipment.’’. 

8 (d) EFFECTIVE DATE.—The amendments made by 

9 this section shall apply with respect to plan years begin10 ning on or after the date of the enactment of this section 

11 and with respect to health insurance coverage issued on 

12 or after such date. 

13 SEC. 4. UPDATING STANDARD DEFINITIONS TO INCLUDE 

14 PROSTHETICS AND CUSTOM ORTHOTICS. 

15 (a) IN GENERAL.—Section 2715(g)(3) of the Public 

16 Health Service Act (42 U.S.C. 300gg–15(g)(3)) is amend17 ed by inserting ‘‘prosthetics, custom orthotics,’’ after 

18 ‘‘emergency medical transportation,’’. 

19 (b) PROSTHETICS; CUSTOM ORTHOTICS.—In devel20 oping standards for the definitions of the terms ‘‘pros21 thetics’’ and ‘‘custom orthotics’’ pursuant to the amend22 ment made by subsection (a), the Secretary shall ensure 

23 that such definitions are consistent with the definitions of 

24 such terms in section 2729(d) of the Public Health Service 

25 Act (as added by section 3(b) of this Act). 


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1 SEC. 5. FEDERAL ADMINISTRATIVE RESPONSIBILITIES. 

2 (a) ASSISTANCE TO ENROLLEES.—The Secretary of 

3 Labor, in consultation with the Secretary of Health and 

4 Human Services, shall provide assistance to enrollees 

5 under group health plans (and health insurance coverage 

6 offered in connection with such plans) to which the amend7 ments made by section 3 apply with any questions or prob8 lems with respect to compliance with the requirements of 

9 such amendments. 

10 (b) AUDITS.—The Secretary of Labor, in consulta11 tion with the Secretary of Health and Human Services, 

12 shall provide for the conduct of random audits of group 

13 health plans (and health insurance coverage offered in 

14 connection with such plans) to ensure that such plans (or 

15 coverage) are in compliance with the amendments made 

16 by section 3. 

17 (c) REGULATIONS.—Not later than 1 year after the 

18 date of the enactment of this Act, the Secretary of Labor, 

19 in consultation with the Secretary of Health and Human 

20 Services, shall promulgate final regulations to carry out 

21 this Act and the amendments made by this Act. 

22 (d) DEFINITIONS.—In this section: 

23 (1) GROUP HEALTH PLAN.—The term ‘‘group 

24 health plan’’ has the meaning given such term in 

25 section 733(a) of the Employee Retirement and In26 come Security Act of 1974 (29 U.S.C. 1191b(a)). 


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1 (2) HEALTH INSURANCE COVERAGE.—The term 

2 ‘‘health insurance coverage’’ has the meaning given 

3 such term in section 733(b)(1) of such Act (29 

4 U.S.C. 1191b(b)(1)). 

Æ 


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