I 
114TH CONGRESS 
1ST SESSION H. R. 1530 
To amend title XVIII of the Social Security Act to refine how Medicare 
pays for orthotics and prosthetics, to improve beneficiary experience 
and outcomes with orthotic and prosthetic care, and to streamline the 
Medicare administrative appeals process, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 23, 2015 
Mr. THOMPSON of Pennsylvania (for himself and Mr. THOMPSON of Cali-
fornia) introduced the following bill; which was referred to the Committee 
on Energy and Commerce, and in addition to the Committee on Ways 
and Means, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to refine 
how Medicare pays for orthotics and prosthetics, to im-
prove beneficiary experience and outcomes with orthotic 
and prosthetic care, and to streamline the Medicare ad-
ministrative appeals process, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
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SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Medicare Orthotics and Prosthetics Improvement Act of 
2015’’. 
(b) TABLE OF CONTENTS.—The table of contents for 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
Sec. 2. Eligibility for Medicare payment for health professionals based on quali-
fications. 
Sec. 3. Modification of requirements applicable under Medicare to the designa-
tion of accreditation organizations for suppliers of orthotics 
and prosthetics. 
Sec. 4. Application of existing accreditation and licensure requirements to cer-
tain prosthetics and custom-fabricated or custom-fitted 
orthotics. 
Sec. 5. Eligibility for Medicare payment for orthotics and prosthetics based on 
supplier qualifications and complexity of care. 
Sec. 6. Orthotist’s and prosthetist’s clinical notes as part of the patient’s med-
ical record. 
Sec. 7. Distinguishing orthotists and prosthetists from suppliers of durable 
medical equipment and supplies. 
Sec. 8. Greater accountability and transparency of recovery audit contractors. 
Sec. 9. Maintaining due process and satisfying the ninety-day statutory period 
for administrative law judge decisions. 
Sec. 10. Clarification about minimal self-adjustment for off-the-shelf orthotics. 
Sec. 11. Regulations. 
SEC. 
2. 
ELIGIBILITY 
FOR 
MEDICARE 
PAYMENT 
FOR 
HEALTH PROFESSIONALS BASED ON QUALI-
FICATIONS. 
(a) IN GENERAL.—Title XVIII of the Social Security 
Act is amended by inserting after section 1863 (42 U.S.C. 
1395z) the following new section: 
‘‘ELIGIBILITY FOR MEDICARE PAYMENT FOR SUPPLIERS 
BASED ON QUALIFICATIONS 
‘‘SEC. 1863A. No payment may be made under this 
part for an item or service that is furnished (i) in a State 
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that requires a provider or supplier to be licensed in order 
to furnish such item or service, unless the provider or sup-
plier furnishing such item or service possesses all applica-
ble licensure from the State, or (ii) in a State that does 
not require a provider or supplier to be licensed in order 
to furnish such item or service, unless the provider or sup-
plier meets all applicable qualifications, as established by 
the Secretary. Applicable qualifications means all applica-
ble accreditations, certifications, and credentials required 
under this part for providers and suppliers, including the 
requirements established under section 427 of the Medi-
care, Medicaid, and SCHIP Benefits Improvement and 
Protections Act of 2000, as enacted into law by section 
1(a)(6) of Public Law 106–554, with these requirements 
to be applicable immediately in accordance with that stat-
utory language even in advance of the Secretary issuing 
applicable regulations under this provision, as well as any 
and all applicable regulations as established by the Sec-
retary, this being noted inasmuch as issuance of these reg-
ulations are approximately fourteen years beyond the stat-
utory requirement for their being issued in final form by 
the Secretary, which it is anticipated the Secretary will 
remedy expeditiously.’’. 
(b) EFFECTIVE DATE.—This section shall take effect 
on the date of enactment of this Act. 
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SEC. 3. MODIFICATION OF REQUIREMENTS APPLICABLE 
UNDER MEDICARE TO THE DESIGNATION OF 
ACCREDITATION ORGANIZATIONS FOR SUP-
PLIERS OF ORTHOTICS AND PROSTHETICS. 
(a) IN GENERAL.—Section 1834(a)(20)(B) of the So-
cial Security Act (42 U.S.C. 1395m(a)(20)(B)) is amend-
ed— 
(1) by striking ‘‘ORGANIZATIONS.—Not later 
than’’ and inserting: ‘‘ORGANIZATIONS.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), not later than’’; and 
(2) by adding after clause (i), as added by 
paragraph (1), the following new clauses: 
‘‘(ii) SPECIAL
REQUIREMENTS
FOR 
ACCREDITATION
OF
SUPPLIERS
OF 
ORTHOTICS AND PROSTHETICS.—For pur-
poses of applying quality standards under 
subparagraph (A) for suppliers (other than 
suppliers described in clause (iii)) of items 
and services described in subparagraph 
(D)(ii), the Secretary shall designate and 
approve independent accreditation organi-
zations under clause (i) only if such orga-
nizations are Boards or programs de-
scribed in subsection (h)(1)(F)(iv). Not 
later than January 1, 2016, the Secretary 
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shall ensure that at least one, and ideally 
multiple, independent accreditation organi-
zations are designated and approved in ac-
cordance with this clause. 
‘‘(iii) 
EXCEPTION.—Suppliers 
de-
scribed in this clause are physicians, occu-
pational therapists, or physical therapists 
who are licensed or otherwise regulated by 
the State in which they are practicing and 
who receive payment under this title, in-
cluding regulations promulgated pursuant 
to this subsection.’’. 
(b) EFFECTIVE DATE.—The designated and ap-
proved organizations must satisfy the requirement of sec-
tion 1834(a)(20)(B)(ii), as added by subsection (a)(2), not 
later than January 1, 2016, regardless of whether such 
organizations are designated or approved as an inde-
pendent accreditation organization before, on, or after the 
date of the enactment of this Act. 
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SEC. 4. APPLICATION OF EXISTING ACCREDITATION AND 
LICENSURE 
REQUIREMENTS 
TO 
CERTAIN 
PROSTHETICS AND CUSTOM-FABRICATED OR 
CUSTOM-FITTED ORTHOTICS. 
(a) IN GENERAL.—Section 1834(h)(1)(F) of the So-
cial Security Act (42 U.S.C. 1395m(h)(1)(F)) is amend-
ed— 
(1) in the heading, by inserting ‘‘OR CUSTOM- 
FITTED’’ after ‘‘CUSTOM-FABRICATED’’; 
(2) in clause (i), by striking ‘‘an item of cus-
tom-fabricated orthotics described in clause (ii) or 
for an item of prosthetics unless such item is’’ and 
inserting ‘‘an item of orthotics or prosthetics, includ-
ing an item of custom-fabricated orthotics described 
in clause (ii), unless such item is’’; 
(3) in clause (ii)(II), by striking ‘‘a list of items 
to which this subparagraph applies’’ and inserting 
‘‘a list of items for purposes of clause (i)’’; 
(4) in clause (iii)(III), by striking ‘‘to provide 
or manage the provision of prosthetics and custom- 
designed or -fabricated orthotics’’ and inserting ‘‘to 
provide or manage the provision of orthotics and 
prosthetics (and custom-designed or -fabricated 
orthotics, in the case of an item described in clause 
(ii))’’; and 
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(5) by adding at the end the following new 
clause: 
‘‘(v) EXEMPTION OF OFF-THE-SHELF 
ORTHOTICS INCLUDED IN A COMPETITIVE 
ACQUISITION
PROGRAM.—This 
subpara-
graph shall not apply to an item of 
orthotics described in paragraph (2)(C) of 
section 1847(a) furnished on or after Jan-
uary 1, 2016, that is included in a com-
petitive acquisition area under such sec-
tion.’’. 
(b) EFFECTIVE DATE.—The amendments made by 
subsection (a) shall apply to orthotics and prosthetics fur-
nished on or after January 1, 2016. 
SEC. 
5. 
ELIGIBILITY 
FOR 
MEDICARE 
PAYMENT 
FOR 
ORTHOTICS AND PROSTHETICS BASED ON 
SUPPLIER 
QUALIFICATIONS 
AND 
COM-
PLEXITY OF CARE. 
Section 1834(h) of the Social Security Act (42 U.S.C. 
1395m(h)) is amended— 
(1) in paragraph (1)(F)(iii), in the matter pre-
ceding subclause (I), by striking ‘‘other individual 
who’’ and inserting ‘‘other individual who, with re-
spect to the provision of orthotics and prosthetics 
furnished on or after January 1, 2016, and subject 
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to paragraph (5)(A), satisfies all applicable criteria 
of the provider qualification designation for such 
category described in the respective clause, and 
who’’; 
(2) in paragraph (1)(F)(iv), by inserting before 
the period the following: ‘‘and, with respect to the 
provision of orthotics and prosthetics furnished on 
or after January 1, 2016, and subject to paragraph 
(5)(A), satisfies all applicable criteria of the provider 
qualification designation for such orthotic or pros-
thetic’’; and 
(3) by adding at the end the following new 
paragraph: 
‘‘(5) ELIGIBILITY
FOR
PAYMENT
BASED
ON 
SUPPLIER
QUALIFICATIONS
AND
COMPLEXITY
OF 
CARE.— 
‘‘(A) CONSIDERATIONS
FOR
ELIGIBILITY 
FOR PAYMENTS.— 
‘‘(i) 
IN
GENERAL.—In 
applying 
clauses (iii) and (iv) of paragraph (1)(F) 
for purposes of determining whether pay-
ment may be made under this subsection 
for orthotics and prosthetics furnished on 
or after January 1, 2016, the Secretary 
shall take into account the complexity of 
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the respective item and, subject to clauses 
(ii), (iii), and (iv), the qualifications of the 
individual or entity furnishing and fabri-
cating such respective item in accordance 
with this paragraph. 
‘‘(ii) INDIVIDUALS AND ENTITIES EX-
EMPTED FROM SUPPLIER QUALIFICATION 
CRITERIA.—With respect to the provision 
of orthotics or prosthetics, any criteria for 
supplier qualifications shall not apply to 
physicians, 
occupational 
therapists, 
or 
physical therapists who are licensed or oth-
erwise regulated by the State in which they 
are practicing and who receive payment 
under this title, including regulations pro-
mulgated pursuant to this subsection, for 
the provision of orthotics and prosthetics. 
‘‘(iii) SUPPLIERS MEDICARE-ELIGIBLE 
PRIOR TO JANUARY 1, 2016 EXEMPTED.— 
In the case of a qualified supplier who is 
eligible to receive payment under this title 
before January 1, 2016, with respect to 
the provision of orthotics and prosthetics, 
any new criteria for provider qualifications 
established after such date shall not apply 
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to such supplier, for the furnishing or fab-
rication of such an item. 
‘‘(iv) MODIFICATIONS.—The Secretary 
shall, in consultation with the Boards and 
programs 
described 
in 
paragraph 
(1)(F)(iv), periodically review the criteria 
for supplier qualifications and may imple-
ment by regulation any modifications to 
such criteria, as determined appropriate in 
accordance with such consultation. Any 
such modifications shall take effect no ear-
lier than January 1, 2016. 
‘‘(B) ASSIGNMENT OF BILLING CODES.— 
For purposes of subparagraph (A), the Sec-
retary, in consultation with representatives of 
the fields of occupational therapy, physical ther-
apy, orthotics, and prosthetics, shall utilize and 
incorporate the set of L-codes listed, as of the 
date of enactment of this paragraph, in the 
Centers for Medicare & Medicaid Services docu-
ment entitled Transmittal 656 (CMS Pub. 100– 
04, Change Request 3959, August 19, 2005). 
Transmittal 656 shall be the controlling source 
of category, product, and code assignments for 
the orthotics and prosthetics care, using the 
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supplier qualification designation for each 
HCPCS code as stated in such document. In 
the case that Transmittal 656 is updated, re-
issued, or replaced by a subsequent document, 
the previous sentence shall be applied with re-
spect to the most recent update, reissuance, or 
replacement of such document.’’. 
SEC. 6. ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES 
AS 
PART 
OF 
THE 
PATIENT’S 
MEDICAL 
RECORD. 
Section 1834(h) of the Social Security Act (42 U.S.C. 
1395m(h)), as amended by section 5, is amended by add-
ing at the end the following new paragraph: 
‘‘(6) 
DOCUMENTATION
CREATED
BY 
ORTHOTISTS AND PROSTHETISTS.—With respect to 
claims filed after August 11, 2011, for purposes of 
determining the reasonableness, medical necessity, 
and functional level (applicable to prosthetics) of 
prosthetic devices and orthotics and prosthetics, doc-
umentation created by an orthotist or prosthetist 
shall be considered part of the patient’s medical 
record and, consistent with the treatment of orthotic 
and prosthetic patient care delivery stated in the 
health care professional exception provided in clause 
(ii) of subsection (a)(20)(F), shall be given the same 
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consideration as documentation created by other 
health professionals, including physicians, nurse 
practitioners, occupational therapists, and physical 
therapists. For claims filed before date of enactment 
of this Act, this paragraph shall not apply to those 
appeals of claim denials that have been waived, de-
nied at the last level of appeal, or otherwise set-
tled.’’. 
SEC. 7. DISTINGUISHING ORTHOTISTS AND PROSTHETISTS 
FROM SUPPLIERS OF DURABLE MEDICAL 
EQUIPMENT AND SUPPLIES. 
(a) REQUIREMENTS FOR SUPPLIERS OF MEDICAL 
EQUIPMENT AND SUPPLIES.—Section 1834(j)(5) of the 
Social Security Act (42 U.S.C. 1395m(j)(5)) is amended 
by striking subparagraph (C). 
(b) 
REQUIREMENTS
FOR
ORTHOTISTS
AND 
PROSTHETISTS.—Section 1834 of the Social Security Act 
(42 U.S.C. 1395m) is amended by adding at the end the 
following new subsection: 
‘‘(r) 
REQUIREMENTS
FOR
ORTHOTISTS
AND 
PROSTHETISTS.— 
‘‘(1) ISSUANCE
AND
RENEWAL
OF
SUPPLIER 
NUMBER.— 
‘‘(A) PAYMENT.— 
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‘‘(i) IN GENERAL.—No payment may 
be made under this part to an orthotic or 
prosthetic supplier unless such orthotic or 
prosthetic supplier obtains (and renews at 
such intervals as the Secretary may re-
quire) a supplier number; provided, how-
ever, that providers otherwise permitted to 
receive payment for orthotics and pros-
thetics under Part A may continue to re-
ceive such payment without interruption. 
‘‘(B) STANDARDS FOR POSSESSING A SUP-
PLIER NUMBER.—An orthotic and/or prosthetic 
supplier may not obtain a supplier number un-
less the supplier meets standards prescribed by 
the Secretary that include requirements that 
the orthotic/prosthetic supplier (and, where ap-
plicable, the orthotist or prosthetist)— 
‘‘(i) comply with all applicable State 
and Federal licensure and regulatory re-
quirements; 
‘‘(ii) acquire accreditation from the 
American 
Board 
for 
Certification 
in 
Orthotics, Prosthetics and Pedorthics, Inc. 
(ABC) or the Board of Certification/Ac-
creditation, International (BOC), or other 
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