I 

110TH CONGRESS 

2D SESSION H. R. 5615 

To provide parity under group health plans and group health insurance 

coverage in the provision of benefits for prosthetic devices and components and benefits for other medical and surgical services. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 13, 2008 

Mr. ANDREWS (for himself, Mr. GEORGE MILLER of California, Mr. PLATTS, 

Mr. LINCOLN DIAZ-BALART of Florida, and Mr. MARIO DIAZ-BALART of 

Florida) introduced the following bill; which was referred to the Committee on Education and Labor 

A BILL 

To provide parity under group health plans and group health 

insurance coverage in the provision of benefits for prosthetic devices and components 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, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

4 This Act may be cited as the ‘‘Group Health Plan 

5 Prosthetics Parity Act of 2007’’. 

6 SEC. 2. FINDINGS; PURPOSE. 

7 (a) FINDINGS.—Congress finds the following: 


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1 (1) There are more than 1,800,000 people in 

2 the United States living with limb loss. 

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

4 people in the United States who undergo amputa5 tion. 

6 (3) In addition, United States military per7 sonnel serving in Iraq and Afghanistan and around 

8 the world have sustained traumatic injuries resulting 

9 in amputation. 

10 (4) The number of amputations in the United 

11 States is projected to increase in the years ahead 

12 due to rising incidence of diabetes and other chronic 

13 illness. 

14 (5) Those suffering from limb loss can and 

15 want to regain their lives as productive members of 

16 society. 

17 (6) Prosthetic devices enable amputees to con18 tinue working and living productive lives. 

19 (7) Insurance companies have begun to limit re20 imbursement of prosthetic equipment costs at unre21 alistic levels or not at all and often restrict coverage 

22 over a person’s lifetime, which shifts costs onto the 

23 Medicare and Medicaid programs. 

24 (8) Eight States have addressed this problem 

25 and have enacted prosthetic parity legislation. 


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1 (9) Prosthetic parity legislation has been intro2 duced and is being actively considered in 30 States. 

3 (10) The States in which prosthetic parity laws 

4 have been enacted have found there to be minimal 

5 or no increases in insurance premiums and have re6 duced Medicare and Medicaid costs. 

7 (11) Prosthetic parity legislation will not add to 

8 the size of government or to the costs associated 

9 with the Medicare or Medicaid programs. 

10 (12) If coverage for prosthetic devices and com11 ponents are offered by a group health insurance pol12 icy, then providing such coverage of prosthetic de13 vices on par with other medical and surgical benefits 

14 will not increase the incidence of amputations or the 

15 number of individuals for which a prosthetic device 

16 would be medically necessary and appropriate. 

17 (13) In States where prosthetic parity legisla18 tion has been enacted, amputees are able to return 

19 to a productive life, State funds have been saved, 

20 and the health insurance industry has continued to 

21 prosper. 

22 (14) Prosthetic services allow people to return 

23 more quickly to their preexisting work. 

24 (b) PURPOSE.—The purpose of this Act is to require 

25 that each group health plan that provides both coverage 


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1 for prosthetic devices and components and medical and 

2 surgical benefits, provide such coverage under terms and 

3 conditions that are no less favorable than the terms and 

4 conditions under which such benefits are provided under 

5 such plan. 

6 SEC. 3. PROSTHETICS PARITY UNDER ERISA. 

7 (a) IN GENERAL.—Subpart B of part 7 of subtitle 

8 B of title I of the Employee Retirement Income Security 

9 Act of 1974 is amended by inserting after section 713 (29 

10 U.S.C. 1185b) the following new section: 

11 ‘‘SEC. 714. PROSTHETICS PARITY. 

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

13 plan (or health insurance coverage offered in connection 

14 with such a plan) that provides both medical and surgical 

15 benefits and benefits for prosthetic devices and compo16 nents (as defined under subsection (d)(1))— 

17 ‘‘(1) such benefits for prosthetic devices and 

18 components under the plan (or coverage) shall be 

19 provided under terms and conditions that are no less 

20 favorable than the terms and conditions applicable 

21 to substantially all medical and surgical benefits pro22 vided under the plan (or coverage); 

23 ‘‘(2) such benefits for prosthetic devices and 

24 components under the plan (or coverage) may not be 

25 subject to separate financial requirements (as deVerDate Aug 31 2005 06:09 Mar 14, 2008 Jkt 069200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H5615.IH H5615

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1 fined in subsection (d)(2)) that are applicable only 

2 with respect to such benefits, and any financial re3 quirements applicable to such benefits may be no 

4 more restrictive than the financial requirements ap5 plicable to substantially all medical and surgical ben6 efits provided under the plan (or coverage); and 

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

8 subsection (d)(3)) applicable to such benefits for 

9 prosthetic devices and components under the plan 

10 (or coverage) may not be more restrictive than the 

11 treatment limitations applicable to substantially all 

12 medical and surgical benefits provided under the 

13 plan (or coverage). 

14 ‘‘(b) IN-NETWORK AND OUT-OF-NETWORK STAND15 ARDS.— 

16 ‘‘(1) IN GENERAL.—In the case of a group 

17 health plan (or health insurance coverage offered in 

18 connection with such a plan) that provides both 

19 medical and surgical benefits and benefits for pros20 thetic devices and components, and that provides 

21 both in-network benefits for prosthetic devices and 

22 components and out-of-network benefits for pros23 thetic devices and components, the requirements of 

24 this section shall apply separately with respect to 

25 benefits provided under the plan (or coverage) on an 


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1 in-network basis and benefits provided under the 

2 plan (or coverage) on an out-of-network basis. 

3 ‘‘(2) CLARIFICATION.—Nothing in paragraph 

4 (1) shall be construed as requiring that a group 

5 health plan (or health insurance coverage offered in 

6 connection with such a plan) eliminate an out-of-net7 work provider option from such plan (or coverage) 

8 pursuant to the terms of the plan (or coverage). 

9 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

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

11 group health plan (or health insurance coverage of12 fered in connection with such a plan) that requires, 

13 as a condition of coverage or payment for prosthetic 

14 devices and components under the plan (or cov15 erage), prior authorization, such prior authorization 

16 must be required in the same manner as prior au17 thorization is required by the plan (or coverage) as 

18 a condition of coverage or payment for all similar 

19 benefits provided under the plan (or coverage). 

20 ‘‘(2) LIMITATION ON MANDATED BENEFITS.— 

21 Required benefits for prosthetic devices and compo22 nents under this section are limited to the most ap23 propriate model that adequately meets the medical 

24 requirements of the patient, as determined by the 

25 treating physician of the patient. 


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1 ‘‘(3) COVERAGE FOR REPAIR OR REPLACE2 MENT.—Benefits for prosthetic devices and compo3 nents required under this section shall include cov4 erage for repair or replacement of prosthetic devices 

5 and components, if the repair or replacement is de6 termined appropriate by the treating physician of 

7 the patient involved. 

8 ‘‘(4) ANNUAL OR LIFETIME DOLLAR LIMITA9 TIONS.—A group health plan (or health insurance 

10 coverage offered in connection with such a plan) 

11 may not impose any annual or lifetime dollar limita12 tion on benefits for prosthetic devices and compo13 nents unless such limitation applies in the aggregate 

14 to all medical and surgical benefits provided under 

15 the plan (or coverage) and benefits for prosthetic de16 vices and components. 

17 ‘‘(d) DEFINITIONS.—For the purposes of this section: 

18 ‘‘(1) PROSTHETIC DEVICES AND COMPO19 NENTS.—The term ‘prosthetic devices and compo20 nents’ means the items and services described in 

21 paragraphs (9) and (12) of section 1861(s) of the 

22 Social Security Act and includes external breast 

23 prostheses incident to mastectomy resulting from 

24 breast cancer. 


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1 ‘‘(2) FINANCIAL REQUIREMENTS.—The term 

2 ‘financial requirements’ includes deductibles, coin3 surance, co-payments, other cost sharing, and limita4 tions on the total amount that may be paid by a 

5 participant or beneficiary with respect to benefits 

6 under the plan or health insurance coverage and also 

7 includes the application of annual and lifetime lim8 its. 

9 ‘‘(3) TREATMENT LIMITATIONS.—The term 

10 ‘treatment limitations’ includes limits on the fre11 quency of treatment, number of visits, days of cov12 erage, or other similar limits on the scope or dura13 tion of treatment.’’. 

14 (b) CLERICAL AMENDMENT.—The table of contents 

15 in section 1 of such Act is amended by inserting after the 

16 item relating to section 713 the following new item: 

‘‘Sec. 714. Prosthetics parity.’’. 

17 (c) EFFECTIVE DATE.—The amendments made by 

18 this section shall apply with respect to group health plans 

19 (and health insurance coverage offered in connection with 

20 group health plans) for plan years beginning on or after 

21 the date of the enactment of this Act. 

22 SEC. 4. FEDERAL ADMINISTRATIVE RESPONSIBILITIES. 

23 (a) ASSISTANCE TO PLAN PARTICIPANTS AND BENE24 FICIARIES.—The Secretary of Labor shall provide for as25 sistance to participants and beneficiaries under such plans 


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1 with any questions or problems regarding compliance with 

2 the requirements of this section. 

3 (b) AUDITS.—The Secretary of Labor shall provide 

4 for the conduct of random audits of group health plans 

5 (and health insurance coverage offered in connection with 

6 such plans) to ensure that such plans are in compliance 

7 with section 714 of the Employee Retirement Income Se8 curity Act of 1974, as added by section 3. 

9 (c) GAO STUDY.— 

10 (1) STUDY.—The Comptroller General of the 

11 United States shall conduct a study that evaluates 

12 the effect of the implementation of the amendments 

13 made by this Act on the cost of health insurance 

14 coverage, on access to health insurance coverage (in15 cluding the availability of in-network providers), on 

16 the quality of health care, on benefits and coverage 

17 for prosthetic devices and components, on any addi18 tional cost or savings to group health plans, on State 

19 prosthetic devices and components benefit mandate 

20 laws, on the business community and the Federal 

21 Government, and on other issues as determined ap22 propriate by the Comptroller General. 

23 (2) REPORT.—Not later than 2 years after the 

24 date of the enactment of this Act, the Comptroller 

25 General of the United States shall prepare and subVerDate Aug 31 2005 06:09 Mar 14, 2008 Jkt 069200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H5615.IH H5615

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1 mit to the appropriate committees of Congress a re2 port containing the results of the study conducted 

3 under paragraph (1). 

4 (d) REGULATIONS.—Not later than 1 year after the 

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

6 shall promulgate final regulations to carry out this Act 

7 and the amendments made by this Act. 

Æ 


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