II 

110TH CONGRESS 

2D SESSION S. 3517 

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 

prosthetic devices and components and benefits for other medical and 

surgical services. 

IN THE SENATE OF THE UNITED STATES 

SEPTEMBER 18 (legislative day, SEPTEMBER 17), 2008 

Ms. SNOWE (for herself, Mr. HARKIN, Mr. INOUYE, and Mr. FEINGOLD) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

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 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. 

4 This Act may be cited as the ‘‘Prosthetics Parity Act 

5 of 2008’’. 


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1 SEC. 2. FINDINGS AND PURPOSE. 

2 (a) FINDINGS.—Congress makes the following find3 ings: 

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

5 the United States living with limb loss. 

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

7 people in the United States who undergo amputation 

8 procedures. 

9 (3) In addition, United States military per10 sonnel serving in Iraq and Afghanistan and around 

11 the world have sustained traumatic injuries resulting 

12 in amputation. 

13 (4) The number of amputations in the United 

14 States is projected to increase in the years ahead 

15 due to the rising incidence of diabetes and other 

16 chronic illness. 

17 (5) Those suffering from limb loss can and 

18 want to regain their lives as productive members of 

19 society. 

20 (6) Prosthetic devices enable amputees to con21 tinue working and living productive lives. 

22 (7) Insurance companies have begun to limit re23 imbursement of prosthetic equipment costs to unre24 alistic levels or not at all and often restrict coverage 

25 over an individual’s lifetime, which shifts costs onto 

26 the Medicare and Medicaid programs. 


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1 (8) Eleven States have addressed this problem 

2 and have prosthetic parity legislation. 

3 (9) Prosthetic parity legislation has been intro4 duced and is being actively considered in 30 States. 

5 (10) The States in which prosthetic parity laws 

6 have been enacted have found there to be minimal 

7 or no increases in insurance premiums and have re8 duced Medicare and Medicaid costs. 

9 (11) Prosthetic parity legislation will not add to 

10 the size of government or to the costs associated 

11 with the Medicare and Medicaid programs. 

12 (12) If coverage for prosthetic devices and com13 ponents are offered by a group health insurance pol14 icy, then providing such coverage of prosthetic de15 vices on par with other medical and surgical benefits 

16 will not increase the incidence of amputations or the 

17 number of individuals for which a prosthetic device 

18 would be medically necessary and appropriate. 

19 (13) In States where prosthetic parity legisla20 tion has been enacted, amputees are able to return 

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

22 and the health insurance industry has continued to 

23 prosper. 

24 (14) Prosthetic services allow people to return 

25 more quickly to their preexisting work. 


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1 (b) PURPOSE.—It is te purpose of this Act to require 

2 that each group health plan that provides both coverage 

3 for prosthetic devices and components and medical and 

4 surgical benefits, provide such coverage under terms and 

5 conditions that are no less favorable that the terms and 

6 conditions under which such benefits are provided for 

7 other benefits under such plan. 

8 SEC. 3. PROSTHETICS PARITY. 

9 (a) ERISA.— 

10 (1) IN GENERAL.—Subpart B of part 7 of sub11 title B of title I of the Employee Retirement Income 

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

13 amended by adding at the end the following: 

14 ‘‘SEC. 714. PROSTHETICS PARITY. 

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

16 plan (or health insurance coverage offered in connection 

17 with a group health plan) that provides both medical and 

18 surgical benefits for prosthetic devices and components (as 

19 defined under subsection (d)(1))— 

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

21 components under the plan (or coverage) shall be 

22 provided under terms and conditions that are no less 

23 favorable than the terms and conditions applicable 

24 to substantially all medical and surgical benefits pro25 vided under the plan (or coverage); 


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

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

3 subject to separate financial requirements (as de4 fined in subsection (d)(2)) that are applicable only 

5 with respect to such benefits, and any financial re6 quirements applicable to such benefits shall be no 

7 more restrictive than the financial requirements ap8 plicable to substantially all medical and surgical ben9 efits provided under the plan (or coverage); and 

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

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

12 prosthetic devices and components under the plan 

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

14 treatment limitations applicable to substantially all 

15 medical and surgical benefits provided under the 

16 plan ( or coverage). 

17 ‘‘(b) IN NETWORK AND OUT-OF-NETWORK STAND18 ARDS.— 

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

20 health plan (or health insurance coverage offered in 

21 connection with a group health plan) that provides 

22 both medical and surgical benefits and benefits for 

23 prosthetic devices and components, and that pro24 vides both in-network benefits for prosthetic devices 

25 and components and out-of-network benefits for 


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1 prosthetic devices and components, the requirements 

2 of this section shall apply separately with respect to 

3 benefits under the plan (or coverage) on an in-net4 work basis and benefits provided under the plan (or 

5 coverage) on an out-of-network basis. 

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

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

8 health plan (or health insurance coverage offered in 

9 connection with a group health plan) eliminate an 

10 out-of-network provider option from such plan (or 

11 coverage) pursuant to the terms of the plan (or cov12 erage). 

13 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

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

15 group health plan (or health insurance coverage of16 fered in connection with a group health plan) that 

17 requires, as a condition of coverage or payment for 

18 prosthetic devices and components under the plan 

19 (or coverage), prior authorization, such prior author20 ization must be required in the same manner as 

21 prior authorization is required by the plan (or cov22 erage) as a condition of coverage or payment for all 

23 similar benefits provided under the plan (or cov24 erage). 


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

2 Coverage for required benefits for prosthetic devices 

3 and components under this section shall be limited 

4 to coverage of the most appropriate device or compo5 nent model that adequately meets the medical re6 quirements of the patient, as determined by the 

7 treating physician of the patient involved. 

8 ‘‘(3) COVERAGE FOR REPAIR OR REPLACE9 MENT.—Benefits for prosthetic devices and compo10 nents required under this section shall include cov11 erage for the repair or replacement of prosthetic de12 vices and components, if the repair or replacement 

13 is determined appropriate by the treating physician 

14 of the patient involved. 

15 ‘‘(4) ANNUAL OR LIFETIME DOLLAR LIMITA16 TIONS.—A group health plan (or health insurance 

17 coverage offered in connection with a group health 

18 plan) shall not impose any annual or lifetime dollar 

19 limitation on benefits for prosthetic devices and com20 ponents required to be covered under this section 

21 unless such limitation applies in the aggregate to all 

22 medical and surgical benefits provided under the 

23 plan (or coverage) and benefits for prosthetic devices 

24 components. 

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


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1 ‘‘(1) PROSTHETIC DEVICES AND COMPO2 NENTS.—The term ‘prosthetic devices and compo3 nents’ means those devices and components that 

4 may be used to replace, in whole or in part, an arm 

5 or leg, as well as the services required to do so and 

6 includes external breast prostheses incident to mas7 tectomy resulting from breast cancer. 

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

9 ‘financial requirements’ includes deductibles, coin10 surance, co-payments, other cost sharing, and limita11 tions on the total amount that may be paid by a 

12 participant or beneficiary with respect to benefits 

13 under the plan or health insurance coverage and also 

14 includes the application of annual and lifetime lim15 its. 

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

17 ‘treatment limitations’ includes limits on the fre18 quency of treatment, number of visits, days of cov19 erage, or other similar limits on the scope or dura20 tion of treatment.’’. 

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 713 the following: 

‘‘Sec. 714. Prosthetics parity.’’. 


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1 (b) PHSA.—Subpart 2 of part A of title XXVII of 

2 the Public Health Service Act (42 U.S.C. 300gg–4 et seq.) 

3 is amended by adding at the end the following: 

4 ‘‘SEC. 2707. PROSTHETICS PARITY. 

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

6 plan (or health insurance coverage offered in connection 

7 with a group health plan) that provides both medical and 

8 surgical benefits for prosthetic devices and components (as 

9 defined under subsection (d)(1))— 

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

11 components under the plan (or coverage) shall be 

12 provided under terms and conditions that are no less 

13 favorable than the terms and conditions applicable 

14 to substantially all medical and surgical benefits pro15 vided under the plan (or coverage); 

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

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

18 subject to separate financial requirements (as de19 fined in subsection (d)(2)) that are applicable only 

20 with respect to such benefits, and any financial re21 quirements applicable to such benefits shall be no 

22 more restrictive than the financial requirements ap23 plicable to substantially all medical and surgical ben24 efits provided under the plan (or coverage); and 


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

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

3 prosthetic devices and components under the plan 

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

5 treatment limitations applicable to substantially all 

6 medical and surgical benefits provided under the 

7 plan ( or coverage). 

8 ‘‘(b) IN NETWORK AND OUT-OF-NETWORK STAND9 ARDS.— 

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

11 health plan (or health insurance coverage offered in 

12 connection with a group health plan) that provides 

13 both medical and surgical benefits and benefits for 

14 prosthetic devices and components, and that pro15 vides both in-network benefits for prosthetic devices 

16 and components and out-of-network benefits for 

17 prosthetic devices and components, the requirements 

18 of this section shall apply separately with respect to 

19 benefits under the plan (or coverage) on an in-net20 work basis and benefits provided under the plan (or 

21 coverage) on an out-of-network basis. 

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

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

24 health plan (or health insurance coverage offered in 

25 connection with a group health plan) eliminate an 


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1 out-of-network provider option from such plan (or 

2 coverage) pursuant to the terms of the plan (or cov3 erage). 

4 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

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

6 group health plan (or health insurance coverage of7 fered in connection with a group health plan) that 

8 requires, as a condition of coverage or payment for 

9 prosthetic devices and components under the plan 

10 (or coverage), prior authorization, such prior author11 ization must be required in the same manner as 

12 prior authorization is required by the plan (or cov13 erage) as a condition of coverage or payment for all 

14 similar benefits provided under the plan (or cov15 erage). 

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

17 Coverage for required benefits for prosthetic devices 

18 and components under this section shall be limited 

19 to coverage of the most appropriate device or compo20 nent model that adequately meets the medical re21 quirements of the patient, as determined by the 

22 treating physician of the patient involved. 

23 ‘‘(3) COVERAGE FOR REPAIR OR REPLACE24 MENT.—Benefits for prosthetic devices and compo25 nents required under this section shall include covVerDate Aug 31 2005 05:19 Sep 19, 2008 Jkt 069200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\S3517.IS S3517

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1 erage for the repair or replacement of prosthetic de2 vices and components, if the repair or replacement 

3 is determined appropriate by the treating physician 

4 of the patient involved. 

5 ‘‘(4) ANNUAL OR LIFETIME DOLLAR LIMITA6 TIONS.—A group health plan (or health insurance 

7 coverage offered in connection with a group health 

8 plan) shall not impose any annual or lifetime dollar 

9 limitation on benefits for prosthetic devices and com10 ponents required to be covered under this section 

11 unless such limitation applies in the aggregate to all 

12 medical and surgical benefits provided under the 

13 plan (or coverage) and benefits for prosthetic devices 

14 components. 

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

16 ‘‘(1) PROSTHETIC DEVICES AND COMPO17 NENTS.—The term ‘prosthetic devices and compo18 nents’ means those devices and components that 

19 may be used to replace, in whole or in part, an arm 

20 or leg, as well as the services required to do so and 

21 includes external breast prostheses incident to mas22 tectomy resulting from breast cancer. 

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

24 ‘financial requirements’ includes deductibles, coin25 surance, co-payments, other cost sharing, and limitaVerDate Aug 31 2005 05:19 Sep 19, 2008 Jkt 069200 PO 00000 Frm 00012 Fmt 6652 Sfmt 6201 E:\BILLS\S3517.IS S3517

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1 tions on the total amount that may be paid by an 

2 enrollee with respect to benefits under the plan or 

3 health insurance coverage and also includes the ap4 plication of annual and lifetime limits. 

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

6 ‘treatment limitations’ includes limits on the fre7 quency of treatment, number of visits, days of cov8 erage, or other similar limits on the scope or dura9 tion of treatment.’’. 

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

11 this section shall apply with respect to group health plans 

12 (and health insurance coverage offered in connection with 

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

14 the date of the enactment of this Act. 

15 SEC. 4. FEDERAL ADMINISTRATIVE RESPONSIBILITIES. 

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

17 Labor, in consultation with the Secretary of Health and 

18 Human Services, shall provide assistance to enrollees 

19 under plans or coverage to which the amendment made 

20 by section 3 apply with any questions or problems with 

21 respect to compliance with the requirements of such 

22 amendment. 

23 (b) AUDITS.—The Secretary of Labor, in consulta24 tion with the Secretary of Health and Human Services, 

25 shall provide for the conduct of random audits of group 


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1 health plans (and health insurance coverage offered in 

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

3 coverage) are in compliance with the amendments made 

4 by section (3). 

5 (c) GAO STUDY.— 

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

7 United States shall conduct a study that evaluates 

8 the effect of the implementation of the amendments 

9 made by this Act on the cost of the health insurance 

10 coverage, on access to health insurance coverage (in11 cluding the availability of in-network providers), on 

12 the quality of health care, on benefits and coverage 

13 for prosthetics devices and components, on any addi14 tional cost or savings to group health plans, on State 

15 prosthetic devices and components benefit mandate 

16 laws, on the business community and the Federal 

17 Government, and on other issues as determined ap18 propriate by the Comptroller General. 

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

20 date of the enactment of this Act, the Comptroller 

21 General of the United States shall prepare and sub22 mit to the appropriate committee of Congress a re23 port containing the results of the study conducted 

24 under paragraph (1). 


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

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

3 in consultation with the Secretary of Health and Human 

4 Services, shall promulgate final regulations to carry out 

5 this Act and the amendments made by this Act. 

Æ 


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