```

[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3020 Introduced in House (IH)]

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.

    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, and prosthetic and orthotic care often enables 
        amputees and others with orthopedic impairments to continue 
        working and living productive lives.
            (6) Insurance companies often restrict coverage for 
        prosthetic and orthotic devices and related services over an 
        individual's lifetime, which shifts costs onto individuals and 
        consequently to the Medicare and Medicaid programs.
            (7) Twenty States have addressed this problem and have 
        prosthetic or orthotic parity legislation, which also is being 
        considered actively in other States.
            (8) The States in which prosthetic or orthotic fairness in 
        coverage laws have been enacted have found there to be minimal 
        or no increases in insurance premiums and have reduced Medicare 
        and Medicaid costs.
            (9) Coverage of orthotic and prosthetic devices and related 
        services is only appropriate for individuals missing a limb or 
        having an orthopedic condition in need of treatment. Therefore, 
        a fixed population of individuals are candidates for these 
        devices and related services.
            (10) Appropriate and timely treatment involving prosthetic 
        and orthotic devices and related services allow people to 
        regain health function, preexisting work, and independent 
        living.
            (11) Prosthetic and orthotic devices and related services 
        are a distinct and separate benefit from the durable medical 
        equipment benefit, but this distinction often is not recognized 
        as insurers typically combine these benefits under a combined 
        limit.
            (12) The Patient Protection and Affordable Care Act (Public 
        Law 111-148) and the Health Care and Education Reconciliation 
        Act (Public Law 111-152), include rehabilitative and 
        habilitative services as an essential health benefit, which 
        legislative history shows is intended to cover prosthetic and 
        orthotic devices and related services.
            (13) The Institute of Medicine concluded that prosthetic 
        and orthotic devices and related services are covered under a 
        typical employer plan.
            (14) However, while lifetime and annual dollar limitations 
        on essential health benefits are prohibited under the Patient 
        Protection and Affordable Care Act (Public Law 111-148) and the 
        Health Care and Education Reconciliation Act (Public Law 111-
        152), other techniques to minimize or eliminate coverage 
        continue to be used across the country and are denying 
        individuals access to medically necessary prosthetic and 
        orthotic devices and related services.
    (b) Purpose.--It is the purpose of this Act to require that each 
group and individual health plan and individual and group health 
insurance coverage 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 FAIRNESS IN COVERAGE.

    (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 FAIRNESS IN COVERAGE.

    ``(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 
        (d)(3)) 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 
        (d)(4)) 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) 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.
    ``(c) 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 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.
    ``(d) 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.
            ``(4) Treatment limitations.--The term `treatment 
        limitations' includes limits on the frequency of treatment, 
        number of visits, specific prescribed components, limits that 
        are more broadly applicable to durable medical equipment, or 
        other similar limits on the amount, duration, or scope of 
        treatment.
    ``(e) 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. 715. Additional market reforms.
``Sec. 716. Prosthetics and custom orthotics parity.''.
    (b) PHSA.--
            (1) In general.--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 a health 
insurance issuer offering group or individual health insurance 
coverage, 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) Patient Access.--A group health plan, or health insurance 
issuer offering group or individual health insurance coverage, 
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.
    ``(c) Additional Requirements.--
            ``(1) Prior authorization.--In the case of a group health 
        plan, or health insurance issuer offering group or individual 
        health insurance coverage, 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 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.
    ``(d) 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.
            ``(4) Treatment limitations.--The term `treatment 
        limitations' includes limits on the frequency of treatment, 
        number of visits, specific prescribed components, and limits 
        that are more broadly applicable to durable medical equipment, 
        or other similar limits on the amount, duration, or scope of 
        treatment.
    ``(e) Differentiation From Durable Medical Equipment.--For purposes 
of this section, prosthetics and custom orthotics shall be treated as 
distinct from durable medical equipment.''.
            (2) Application to individual health insurance coverage 
        before 2014.--For purposes of applying section 2729 of the 
        Public Health Service Act, as inserted by paragraph (1), to 
        individual health insurance coverage before 2014, the 
        provisions of such section shall be treated as also included 
        under part B of title XXVII of the Public Health Service Act.
    (c) Internal Revenue Code.--Subchapter B of chapter 100 of subtitle 
K of the Internal Revenue Code of 1986 is amended by adding after 
section 9813 the following:

``SEC. 9814. PROSTHETICS AND CUSTOM ORTHOTICS FAIRNESS IN COVERAGE.

    ``(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) 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.
    ``(c) 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 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) Assistance to enrollees.--The Secretary of the 
        Treasury, in consultation with the Secretary of Health and 
        Human Services, shall provide assistance to enrollees under 
        plans or coverage to which the amendment made by section 3 
        apply with any questions or problems with respect to compliance 
        with the requirements of such amendment.
            ``(5) Audits.--The Secretary of the Treasury, 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).
    ``(d) 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.
            ``(4) Treatment limitations.--The term `treatment 
        limitations' includes limits on the frequency of treatment, 
        number of visits, specific prescribed components, or other 
        similar limits on the scope or duration of treatment.
    ``(e) Differentiation From Durable Medical Equipment.--For purposes 
of this section, prosthetics and custom orthotics shall be treated as 
distinct from durable medical equipment.''.
    (d) Effective Date.--The amendments made by this section shall 
apply with respect to plan years beginning on or after the date of the 
enactment of this section and with respect to health insurance coverage 
issued on or after such date.

SEC. 4. UPDATING STANDARD DEFINITIONS TO INCLUDE PROSTHETICS AND CUSTOM 
              ORTHOTICS.

    (a) In General.--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,''.
    (b) Prosthetics; Custom Orthotics.--In developing standards for the 
definitions of the terms ``prosthetics'' and ``custom orthotics'' 
pursuant to the amendment made by subsection (a), the Secretary shall 
ensure that such definitions are consistent with the definitions of 
such terms in section 2729(d) of the Public Health Service Act (as 
added by section 3(b) of this Act).

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 
amendments made by section 3 apply with any questions or problems with 
respect to compliance with the requirements of such amendments.
    (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) 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.
    (d) Definitions.--In this section:
            (1) Group health plan.--The term ``group health plan'' has 
        the meaning given such term in section 733(a) of the Employee 
        Retirement and Income Security Act of 1974 (29 U.S.C. 
        1191b(a)).
            (2) 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>
```