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 compo-
nents 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 Com-
mittee on Education and Labor 
A BILL 
To provide parity under group health plans and group health 
insurance coverage in the provision of benefits for pros-
thetic devices and components and benefits for other 
medical and surgical services. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
This Act may be cited as the ‘‘Group Health Plan 
Prosthetics Parity Act of 2007’’. 
SEC. 2. FINDINGS; PURPOSE. 
(a) FINDINGS.—Congress finds the following: 
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(1) There are more than 1,800,000 people in 
the United States living with limb loss. 
(2) Every year, there are more than 130,000 
people in the United States who undergo amputa-
tion. 
(3) In addition, United States military per-
sonnel serving in Iraq and Afghanistan and around 
the world have sustained traumatic injuries resulting 
in amputation. 
(4) The number of amputations in the United 
States is projected to increase in the years ahead 
due to rising incidence of diabetes and other chronic 
illness. 
(5) Those suffering from limb loss can and 
want to regain their lives as productive members of 
society. 
(6) Prosthetic devices enable amputees to con-
tinue working and living productive lives. 
(7) Insurance companies have begun to limit re-
imbursement of prosthetic equipment costs at unre-
alistic levels or not at all and often restrict coverage 
over a person’s lifetime, which shifts costs onto the 
Medicare and Medicaid programs. 
(8) Eight States have addressed this problem 
and have enacted prosthetic parity legislation. 
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(9) Prosthetic parity legislation has been intro-
duced and is being actively considered in 30 States. 
(10) The States in which prosthetic parity laws 
have been enacted have found there to be minimal 
or no increases in insurance premiums and have re-
duced Medicare and Medicaid costs. 
(11) Prosthetic parity legislation will not add to 
the size of government or to the costs associated 
with the Medicare or Medicaid programs. 
(12) If coverage for prosthetic devices and com-
ponents are offered by a group health insurance pol-
icy, then providing such coverage of prosthetic de-
vices on par with other medical and surgical benefits 
will not increase the incidence of amputations or the 
number of individuals for which a prosthetic device 
would be medically necessary and appropriate. 
(13) In States where prosthetic parity legisla-
tion has been enacted, amputees are able to return 
to a productive life, State funds have been saved, 
and the health insurance industry has continued to 
prosper. 
(14) Prosthetic services allow people to return 
more quickly to their preexisting work. 
(b) PURPOSE.—The purpose of this Act is to require 
that each group health plan that provides both coverage 
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for prosthetic devices and components and medical and 
surgical benefits, provide such coverage under terms and 
conditions that are no less favorable than the terms and 
conditions under which such benefits are provided under 
such plan. 
SEC. 3. PROSTHETICS PARITY UNDER ERISA. 
(a) IN GENERAL.—Subpart B of part 7 of subtitle 
B of title I of the Employee Retirement Income Security 
Act of 1974 is amended by inserting after section 713 (29 
U.S.C. 1185b) the following new section: 
‘‘SEC. 714. PROSTHETICS PARITY. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan (or health insurance coverage offered in connection 
with such a plan) that provides both medical and surgical 
benefits and benefits for prosthetic devices and compo-
nents (as defined under subsection (d)(1))— 
‘‘(1) such benefits for prosthetic devices and 
components 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 pro-
vided under the plan (or coverage); 
‘‘(2) such benefits for prosthetic devices and 
components under the plan (or coverage) may not be 
subject to separate financial requirements (as de-
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fined in subsection (d)(2)) that are applicable only 
with respect to such benefits, and any financial re-
quirements applicable to such benefits may be no 
more restrictive than the financial requirements ap-
plicable to substantially all medical and surgical ben-
efits provided under the plan (or coverage); and 
‘‘(3) any treatment limitations (as defined in 
subsection (d)(3)) applicable to such benefits for 
prosthetic devices and components 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) IN-NETWORK AND OUT-OF-NETWORK STAND-
ARDS.— 
‘‘(1) IN
GENERAL.—In the case of a group 
health plan (or health insurance coverage offered in 
connection with such a plan) that provides both 
medical and surgical benefits and benefits for pros-
thetic devices and components, and that provides 
both in-network benefits for prosthetic devices and 
components and out-of-network benefits for pros-
thetic devices and components, the requirements of 
this section shall apply separately with respect to 
benefits provided under the plan (or coverage) on an 
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in-network basis and benefits provided under the 
plan (or coverage) on an out-of-network basis. 
‘‘(2) CLARIFICATION.—Nothing in paragraph 
(1) shall be construed as requiring that a group 
health plan (or health insurance coverage offered in 
connection with such a plan) eliminate an out-of-net-
work provider option from such plan (or coverage) 
pursuant to the terms of the plan (or coverage). 
‘‘(c) ADDITIONAL REQUIREMENTS.— 
‘‘(1) PRIOR AUTHORIZATION.—In the case of a 
group health plan (or health insurance coverage of-
fered in connection with such a plan) that requires, 
as a condition of coverage or payment for prosthetic 
devices and components under the plan (or cov-
erage), prior authorization, such prior authorization 
must be required in the same manner as prior au-
thorization is required by the plan (or coverage) as 
a condition of coverage or payment for all similar 
benefits provided under the plan (or coverage). 
‘‘(2) LIMITATION ON MANDATED BENEFITS.— 
Required benefits for prosthetic devices and compo-
nents under this section are limited to the most ap-
propriate model that adequately meets the medical 
requirements of the patient, as determined by the 
treating physician of the patient. 
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‘‘(3) COVERAGE
FOR
REPAIR
OR
REPLACE-
MENT.—Benefits for prosthetic devices and compo-
nents required under this section shall include cov-
erage for repair or replacement of prosthetic devices 
and components, if the repair or replacement is de-
termined appropriate by the treating physician of 
the patient involved. 
‘‘(4) ANNUAL
OR
LIFETIME
DOLLAR
LIMITA-
TIONS.—A group health plan (or health insurance 
coverage offered in connection with such a plan) 
may not impose any annual or lifetime dollar limita-
tion on benefits for prosthetic devices and compo-
nents unless such limitation applies in the aggregate 
to all medical and surgical benefits provided under 
the plan (or coverage) and benefits for prosthetic de-
vices and components. 
‘‘(d) DEFINITIONS.—For the purposes of this section: 
‘‘(1) 
PROSTHETIC
DEVICES
AND
COMPO-
NENTS.—The term ‘prosthetic devices and compo-
nents’ means the items and services described in 
paragraphs (9) and (12) of section 1861(s) of the 
Social Security Act and includes external breast 
prostheses incident to mastectomy resulting from 
breast cancer. 
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‘‘(2) FINANCIAL
REQUIREMENTS.—The term 
‘financial requirements’ includes deductibles, coin-
surance, co-payments, other cost sharing, and limita-
tions on the total amount that may be paid by a 
participant or beneficiary with respect to benefits 
under the plan or health insurance coverage and also 
includes the application of annual and lifetime lim-
its. 
‘‘(3) TREATMENT
LIMITATIONS.—The term 
‘treatment limitations’ includes limits on the fre-
quency of treatment, number of visits, days of cov-
erage, or other similar limits on the scope or dura-
tion of treatment.’’. 
(b) CLERICAL AMENDMENT.—The table of contents 
in section 1 of such Act is amended by inserting after the 
item relating to section 713 the following new item: 
‘‘Sec. 714. Prosthetics parity.’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to group health plans 
(and health insurance coverage offered in connection with 
group health plans) for plan years beginning on or after 
the date of the enactment of this Act. 
SEC. 4. FEDERAL ADMINISTRATIVE RESPONSIBILITIES. 
(a) ASSISTANCE TO PLAN PARTICIPANTS AND BENE-
FICIARIES.—The Secretary of Labor shall provide for as-
sistance to participants and beneficiaries under such plans 
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with any questions or problems regarding compliance with 
the requirements of this section. 
(b) AUDITS.—The Secretary of Labor 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 are in compliance 
with section 714 of the Employee Retirement Income Se-
curity Act of 1974, as added by section 3. 
(c) GAO STUDY.— 
(1) STUDY.—The Comptroller General of the 
United States shall conduct a study that evaluates 
the effect of the implementation of the amendments 
made by this Act on the cost of health insurance 
coverage, on access to health insurance coverage (in-
cluding the availability of in-network providers), on 
the quality of health care, on benefits and coverage 
for prosthetic devices and components, on any addi-
tional cost or savings to group health plans, on State 
prosthetic devices and components benefit mandate 
laws, on the business community and the Federal 
Government, and on other issues as determined ap-
propriate by the Comptroller General. 
(2) REPORT.—Not later than 2 years after the 
date of the enactment of this Act, the Comptroller 
General of the United States shall prepare and sub-
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mit to the appropriate committees of Congress a re-
port containing the results of the study conducted 
under paragraph (1). 
(d) REGULATIONS.—Not later than 1 year after the 
date of the enactment of this Act, the Secretary of Labor 
shall promulgate final regulations to carry out this Act 
and the amendments made by this Act. 
Æ 
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