I 

111TH CONGRESS 

1ST SESSION H. R. 2575 

To provide parity under group health plans and group health insurance 

coverage in the provision of benefits for prosthetic devices and orthotics 

devices, components and benefits for other medical and surgical services. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 21, 2009 

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

DIAZ-BALART of Florida, Mr. PLATTS, Mr. SESTAK, and Mr. AL GREEN

of Texas) 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 orthotics devices, 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 ‘‘Prosthetic and Custom 

5 Orthotic Parity Act of 2009’’. 

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) Eleven 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 (15) Spina bifida occurs in 7 out of every 

25 10,000 live births in the United States. 


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1 (16) For children with spina bifida, access to a 

2 custom orthotic device impacts both their short and 

3 long term mobility, their muscle strength, and over4 all quality of life. As they mature, the orthotic device 

5 allows them to maintain their maximum level of 

6 functionality. This has a profound impact on their 

7 ability to become and remain independent and pro8 ductive members of the community. 

9 (17) Cerebral palsy is one of the most common 

10 congenital (existing before birth or at birth) dis11 orders of childhood. About 10,000 babies per year in 

12 the United States will develop cerebral palsy. 

13 (18) The purpose of a custom orthotic device 

14 for people with cerebral palsy is to protect, such as 

15 stabilizing a fracture during healing; to prevent de16 formity, such as stretching braces worn while the 

17 person sleeps, to help prevent muscle contractures; 

18 and to improve function. This can help kids with 

19 cerebral palsy achieve maximum potential in growth 

20 and development. 

21 (19) If coverage for prosthetic and custom 

22 orthotic devices and related services is offered to in23 dividuals by a group health insurance policy, then 

24 providing such coverage of prosthetic and orthotic 

25 devices on par with other medical and surgical beneVerDate Nov 24 2008 19:17 May 24, 2009 Jkt 079200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\H2575.IH H2575

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1 fits will not increase the incidence of amputations or 

2 the number of individuals for which a prosthetic or 

3 custom orthotic device would be medically necessary 

4 and appropriate. 

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

6 that each group health plan that provides both coverage 

7 for prosthetic devices and components and medical and 

8 surgical benefits, provide such coverage under terms and 

9 conditions that are no less favorable than the terms and 

10 conditions under which such benefits are provided under 

11 such plan. 

12 SEC. 3. PROSTHETICS AND CUSTOM ORTHOTIC DEVICE 

13 PARITY UNDER ERISA. 

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

15 B of title I of the Employee Retirement Income Security 

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

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

18 ‘‘SEC. 715. PROSTHETICS AND CUSTOM ORTHOTIC DEVICE 

19 PARITY. 

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

21 plan (or health insurance coverage offered in connection 

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

23 benefits and benefits for prosthetic devices and compo24 nents and orthotic devices (as defined under subsection 

25 (d)(1))— 


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

2 components and custom orthotic devices and related 

3 services under the plan (or coverage) shall be pro4 vided under terms and conditions that are no less fa5 vorable than the terms and conditions applicable to 

6 substantially all medical and surgical benefits pro7 vided under the plan (or coverage); 

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

9 components and custom orthotic devices and related 

10 services under the plan (or coverage) may not be 

11 subject to separate financial requirements (as de12 fined in subsection (d)(2)) that are applicable only 

13 with respect to such benefits, and any financial re14 quirements applicable to such benefits may 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 (d)(3)) applicable to such benefits for 

20 prosthetic devices and components and custom 

21 orthotic devices and related services under the plan 

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

23 treatment limitations applicable to substantially all 

24 medical and surgical benefits provided under the 

25 plan (or coverage). 


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1 ‘‘(b) IN-NETWORK AND OUT-OF-NETWORK STAND2 ARDS.— 

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

4 health plan (or health insurance coverage offered in 

5 connection with such a plan) that provides both 

6 medical and surgical benefits and benefits for pros7 thetic devices and components and custom orthotic 

8 devices and related services, and that provides both 

9 in-network benefits for prosthetic devices and com10 ponents and out-of-network benefits for prosthetic 

11 devices and components, the requirements of this 

12 section shall apply separately with respect to bene13 fits provided under the plan (or coverage) on an in14 network basis and benefits provided under the plan 

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

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

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

18 health plan (or health insurance coverage offered in 

19 connection with such a plan) eliminate an out-of-net20 work provider option from such plan (or coverage) 

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

22 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

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

24 group health plan (or health insurance coverage of25 fered in connection with such a plan) that requires, 


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1 as a condition of coverage or payment for prosthetic 

2 devices and custom orthotic devices and related serv3 ices under the plan (or coverage), prior authoriza4 tion, such prior authorization must be required in 

5 the same manner as prior authorization is required 

6 by the plan (or coverage) as a condition of coverage 

7 or payment for all similar benefits provided under 

8 the plan (or coverage). 

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

10 Required benefits for prosthetic devices and custom 

11 orthotic devices and related services under this sec12 tion are limited to the most appropriate model that 

13 adequately meets the medical requirements of the 

14 patient, as determined by the treating physician of 

15 the patient. 

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

18 orthotic devices and related services required under 

19 this section shall include coverage for repair or re20 placement of prosthetic devices and components, if 

21 the repair or replacement is determined appropriate 

22 by the treating physician of the patient involved. 

23 ‘‘(4) ANNUAL OR LIFETIME DOLLAR LIMITA24 TIONS.—A group health plan (or health insurance 

25 coverage offered in connection with such a plan) 


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1 may not impose any annual or lifetime dollar limita2 tion on benefits for prosthetic devices and custom 

3 orthotic devices and related services unless such lim4 itation applies in the aggregate to all medical and 

5 surgical benefits provided under the plan (or cov6 erage) and benefits for prosthetic devices and com7 ponents. 

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

9 ‘‘(1) PROSTHETIC DEVICES AND COMPO10 NENTS.—The term ‘prosthetic devices and compo11 nents’ means such devices and components which 

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

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

14 includes external breast prostheses incident to mas15 tectomy resulting from breast cancer. 

16 ‘‘(2) CUSTOM ORTHOTIC DEVICES AND RE17 LATED SERVICES.—The term ‘custom orthotic de18 vices and related services’ means the following: 

19 ‘‘(A) Custom-fabricated orthotics and re20 lated services, which include custom-fabricated 

21 devices that are individually made for a specific 

22 patient, as well as all services and supplies 

23 medically necessary for the effective use of the 

24 orthotic device, including formulating its design, 

25 fabrication, material and component selection, 


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1 measurements, fittings, and static and dynamic 

2 alignments, and instructing the patient in the 

3 use of the device. No other patient would be 

4 able to use this item. A custom fabricated item 

5 is a device which is fabricated based on clini6 cally derived and rectified castings, tracings, 

7 measurements, and/or other images (such as x8 rays) of the body part. The fabrication may in9 volve using calculations, templates and compo10 nents. This process requires the use of basic 

11 materials including, but not limited to plastic, 

12 metal, leather or cloth in the form of uncut or 

13 unshaped sheets, bars, or other basic forms and 

14 involves substantial work such as vacuum form15 ing, cutting, bending, molding, sewing, drilling 

16 and finishing prior to fitting on the patient. 

17 Custom-fabricated devices may be furnished 

18 only by an appropriately credentialed (certified 

19 or licensed) practitioner or accredited supplier 

20 in orthotics and/or prosthetics. These devices 

21 and services are represented by the existing set 

22 of L-codes describing this care currently listed 

23 in Centers for Medicare and Medicaid Services 

24 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 medically nec10 essary for the effective use of the orthotic de11 vice, including formulating its design, fabrica12 tion, material and component selection, meas13 urements, fittings, and static and dynamic 

14 alignments, and instructing the patient in the 

15 use of the device. Custom-fitted high devices 

16 may be furnished only by an appropriately 

17 credentialed (certified or licensed) practitioner 

18 or accredited supplier in orthotics and/or pros19 thetics. These devices and services are rep20 resented by the existing set of L-codes describ21 ing this care currently listed in Centers for 

22 Medicare and Medicaid Services Transmittal 

23 656. 

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

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1 surance, co-payments, other cost sharing, and limita2 tions on the total amount that may be paid by a 

3 participant or beneficiary with respect to benefits 

4 under the plan or health insurance coverage and also 

5 includes the application of annual and lifetime lim6 its. 

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

8 ‘treatment limitations’ includes limits on the fre9 quency of treatment, number of visits, days of cov10 erage, or other similar limits on the scope or dura11 tion of treatment.’’. 

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

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

14 item relating to section 713 the following new item: 

‘‘Sec. 715. Prosthetics and custom orthotic device parity.’’. 

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

16 this section shall apply with respect to group health plans 

17 (and health insurance coverage offered in connection with 

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

19 the date of the enactment of this Act. 

20 SEC. 4. FEDERAL ADMINISTRATIVE RESPONSIBILITIES. 

21 (a) ASSISTANCE TO PLAN PARTICIPANTS AND BENE22 FICIARIES.—The Secretary of Labor shall provide for as23 sistance to participants and beneficiaries under such plans 

24 with any questions or problems regarding compliance with 

25 the requirements of this section. 


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

2 for the conduct of random audits of group health plans 

3 (and health insurance coverage offered in connection with 

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

5 with section 715 of the Employee Retirement Income Se6 curity Act of 1974, as added by section 3. 

7 (c) GAO STUDY.— 

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

9 United States shall conduct a study that evaluates 

10 the effect of the implementation of the amendments 

11 made by this Act on the cost of health insurance 

12 coverage, on access to health insurance coverage (in13 cluding the availability of in-network providers), on 

14 the quality of health care, on benefits and coverage 

15 for prosthetic devices and components, on any addi16 tional cost or savings to group health plans, on State 

17 prosthetic devices and components benefit mandate 

18 laws, on the business community and the Federal 

19 Government, and on other issues as determined ap20 propriate by the Comptroller General. 

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

22 date of the enactment of this Act, the Comptroller 

23 General of the United States shall prepare and sub24 mit to the appropriate committees of Congress a reVerDate Nov 24 2008 19:17 May 24, 2009 Jkt 079200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H2575.IH H2575

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1 port containing the results of the study conducted 

2 under paragraph (1). 

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

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

5 shall promulgate final regulations to carry out this Act 

6 and the amendments made by this Act. 

Æ 


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