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 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 orthotics devices, components and ben-
efits 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. 
This Act may be cited as the ‘‘Prosthetic and Custom 
Orthotic Parity Act of 2009’’. 
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) Eleven 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. 
(15) Spina bifida occurs in 7 out of every 
10,000 live births in the United States. 
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(16) For children with spina bifida, access to a 
custom orthotic device impacts both their short and 
long term mobility, their muscle strength, and over-
all quality of life. As they mature, the orthotic device 
allows them to maintain their maximum level of 
functionality. This has a profound impact on their 
ability to become and remain independent and pro-
ductive members of the community. 
(17) Cerebral palsy is one of the most common 
congenital (existing before birth or at birth) dis-
orders of childhood. About 10,000 babies per year in 
the United States will develop cerebral palsy. 
(18) The purpose of a custom orthotic device 
for people with cerebral palsy is to protect, such as 
stabilizing a fracture during healing; to prevent de-
formity, such as stretching braces worn while the 
person sleeps, to help prevent muscle contractures; 
and to improve function. This can help kids with 
cerebral palsy achieve maximum potential in growth 
and development. 
(19) If coverage for prosthetic and custom 
orthotic devices and related services is offered to in-
dividuals by a group health insurance policy, then 
providing such coverage of prosthetic and orthotic 
devices on par with other medical and surgical bene-
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fits will not increase the incidence of amputations or 
the number of individuals for which a prosthetic or 
custom orthotic device would be medically necessary 
and appropriate. 
(b) PURPOSE.—The purpose of this Act is to require 
that each group health plan that provides both coverage 
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 AND CUSTOM ORTHOTIC DEVICE 
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. 715. PROSTHETICS AND CUSTOM ORTHOTIC DEVICE 
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 and orthotic devices (as defined under subsection 
(d)(1))— 
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‘‘(1) such benefits for prosthetic devices and 
components and custom orthotic devices and related 
services under the plan (or coverage) shall be pro-
vided under terms and conditions that are no less fa-
vorable 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 and custom orthotic devices and related 
services under the plan (or coverage) may not be 
subject to separate financial requirements (as de-
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 and custom 
orthotic devices and related services 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). 
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‘‘(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 custom orthotic 
devices and related services, and that provides both 
in-network benefits for prosthetic devices and com-
ponents and out-of-network benefits for prosthetic 
devices and components, the requirements of this 
section shall apply separately with respect to bene-
fits provided under the plan (or coverage) on an 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, 
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as a condition of coverage or payment for prosthetic 
devices and custom orthotic devices and related serv-
ices under the plan (or coverage), prior authoriza-
tion, 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 benefits provided under 
the plan (or coverage). 
‘‘(2) LIMITATION ON MANDATED BENEFITS.— 
Required benefits for prosthetic devices and custom 
orthotic devices and related services under this sec-
tion are limited to the most appropriate model that 
adequately meets the medical requirements of the 
patient, as determined by the treating physician of 
the patient. 
‘‘(3) COVERAGE
FOR
REPAIR
OR
REPLACE-
MENT.—Benefits for prosthetic devices and custom 
orthotic devices and related services required under 
this section shall include coverage for repair or re-
placement of prosthetic devices and components, if 
the repair or replacement is determined 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) 
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may not impose any annual or lifetime dollar limita-
tion on benefits for prosthetic devices and custom 
orthotic devices and related services unless such lim-
itation applies in the aggregate to all medical and 
surgical benefits provided under the plan (or cov-
erage) and benefits for prosthetic devices and com-
ponents. 
‘‘(d) DEFINITIONS.—For the purposes of this section: 
‘‘(1) 
PROSTHETIC
DEVICES
AND
COMPO-
NENTS.—The term ‘prosthetic devices and compo-
nents’ means such devices and components which 
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 mas-
tectomy resulting from breast cancer. 
‘‘(2) CUSTOM
ORTHOTIC
DEVICES
AND
RE-
LATED SERVICES.—The term ‘custom orthotic de-
vices and related services’ means the following: 
‘‘(A) Custom-fabricated orthotics and re-
lated services, which include custom-fabricated 
devices that are individually made for a specific 
patient, as well as all services and supplies 
medically necessary for the effective use of the 
orthotic device, including formulating its design, 
fabrication, material and component selection, 
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measurements, fittings, and static and dynamic 
alignments, and instructing the patient in the 
use of the device. No other patient would be 
able to use this item. A custom fabricated item 
is a device which is fabricated based on clini-
cally derived and rectified castings, tracings, 
measurements, and/or other images (such as x- 
rays) of the body part. The fabrication may in-
volve using calculations, templates and compo-
nents. This process requires the use of basic 
materials including, but not limited to plastic, 
metal, leather or cloth in the form of uncut or 
unshaped sheets, bars, or other basic forms and 
involves substantial work such as vacuum form-
ing, 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 or accredited supplier 
in orthotics and/or prosthetics. These devices 
and services are represented by the existing set 
of L-codes describing this care currently listed 
in Centers for Medicare and Medicaid Services 
Transmittal 656. 
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‘‘(B) Custom-fitted high orthotics and re-
lated services, which include prefabricated de-
vices that are manufactured with no specific pa-
tient in mind, but that are appropriately sized, 
adapted, modified, and configured (with the re-
quired tools and equipment) to a specific pa-
tient in accordance with a prescription, and 
which no other patient would be able to use, as 
well as all services and supplies medically nec-
essary for the effective use of the orthotic de-
vice, including formulating its design, fabrica-
tion, material and component selection, meas-
urements, fittings, and static and dynamic 
alignments, 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 
or accredited supplier in orthotics and/or pros-
thetics. These devices and services are rep-
resented by the existing set of L-codes describ-
ing this care currently listed in Centers for 
Medicare and Medicaid Services Transmittal 
656. 
‘‘(3) FINANCIAL
REQUIREMENTS.—The term 
‘financial requirements’ includes deductibles, coin-
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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. 
‘‘(4) 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. 715. Prosthetics and custom orthotic device 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 
with any questions or problems regarding compliance with 
the requirements of this section. 
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(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 715 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-
mit to the appropriate committees of Congress a re-
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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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