I 
112TH CONGRESS 
2D SESSION 
H. R. 4175 
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 
prosthetics and custom orthotics and benefits for other medical and 
surgical services. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 8, 2012 
Mr. DENT (for himself and Mr. ANDREWS) introduced the following bill; which 
was referred to the Committee on Energy and Commerce, and in addition 
to the Committee on Education and the Workforce, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
of such provisions as fall within the jurisdiction of the committee con-
cerned 
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 insur-
ance coverage for the provision of benefits for prosthetics 
and custom orthotics 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, 
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SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Insurance Fairness 
for Amputees Act’’. 
SEC. 2. FINDINGS AND PURPOSE. 
(a) FINDINGS.—Congress makes the following find-
ings: 
(1) There are more than 1,700,000 people in 
the United States living with limb loss, many of 
whom are appropriate candidates for prosthetic care. 
A comparable number experience trauma, illness, or 
disability that results in musculoskeletal or neuro-
muscular impairment of the limbs, back, and neck 
requiring the use of orthotic care. 
(2) Every year, there are more than 130,000 
people in the United States who undergo amputation 
procedures. 
(3) In addition, United States military per-
sonnel serving in Iraq and Afghanistan and around 
the world have sustained traumatic injuries resulting 
in amputation and musculoskeletal or neuromuscular 
injury. 
(4) The number of amputations in the United 
States is projected to increase in the years ahead 
due to the rising incidence of diabetes and other 
chronic illness. 
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(5) Those experiencing limb loss and limb dys-
function can and want to regain their lives as pro-
ductive members of society. 
(6) Prosthetic and orthotic care often enables 
amputees and others with orthopedic impairments to 
continue working and living productive lives. 
(7) Insurance companies have begun to limit re-
imbursement of prosthetic and custom orthotic care 
costs to unrealistic levels and often restrict coverage 
over an individual’s lifetime, which shifts costs onto 
the Medicare and Medicaid programs. 
(8) Eighteen States have addressed this prob-
lem and have prosthetic or orthotic parity legisla-
tion. 
(9) Prosthetic and orthotic parity legislation 
has been introduced and is being actively considered 
in 20 States. 
(10) The States in which prosthetic or orthotic 
parity laws have been enacted have found there to 
be minimal or no increases in insurance premiums 
and have reduced Medicare and Medicaid costs. 
(11) Prosthetic or orthotic parity legislation will 
not add to the size of government or to the costs as-
sociated with the Medicare and Medicaid programs. 
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(12) If coverage for prosthetics and custom 
orthotics are offered by a group health insurance 
policy, then providing such prosthetic coverage on 
par with other medical and surgical benefits 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 ap-
propriate. 
(13) In States where prosthetic or orthotic par-
ity legislation has been enacted, amputees and oth-
ers with orthopedic impairments are able to return 
to productive lives, State funds have been saved, and 
the health insurance industry has continued to pros-
per. 
(14) Prosthetic and orthotic devices and related 
services allow people to return more quickly to their 
preexisting work. 
(15) States have, and should continue to be 
permitted to, create consumer protections that ex-
ceed the Federal floor of protection provided for in 
this Act. 
(b) PURPOSE.—It is the purpose of this Act to re-
quire that each group health plan that provides medical 
and surgical benefits and also provides coverage for pros-
thetics or custom orthotics (or both), provide such cov-
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erage under terms and conditions that are no less favor-
able than the terms and conditions under which medical 
and surgical benefits are provided under such plan. 
SEC. 3. PROSTHETICS AND CUSTOM ORTHOTICS PARITY. 
(a) ERISA.— 
(1) IN GENERAL.—Subpart B of part 7 of sub-
title B of title I of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1185 et seq.) is 
amended by adding at the end the following: 
‘‘SEC. 716. PROSTHETICS AND CUSTOM ORTHOTICS PARITY. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan (or health insurance coverage offered in connection 
with a group health plan) that provides medical and sur-
gical benefits and also provides benefits for prosthetics or 
custom orthotics (as defined under paragraphs (1) and (2) 
of subsection (e)) (or both)— 
‘‘(1) such benefits for prosthetics or custom 
orthotics (or both) under the plan (or coverage) shall 
be provided under terms and conditions that are no 
less favorable than the terms and conditions applica-
ble to substantially all medical and surgical benefits 
provided under the plan (or coverage); 
‘‘(2) such benefits for prosthetics or custom 
orthotics (or both) under the plan (or coverage) may 
not be subject to separate financial requirements (as 
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defined in subsection (e)(2)) that are applicable only 
with respect to such benefits, and any financial re-
quirements applicable to such benefits shall 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 (e)(3)) applicable to such benefits for 
prosthetics or custom orthotics (or both) 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 a group health plan) that provides 
medical or surgical benefits and also provides bene-
fits for prosthetics or custom orthotics (or both), 
and that provides both in-network benefits for pros-
thetics and custom orthotics and out-of-network ben-
efits for prosthetics and custom orthotics, the re-
quirements of this section shall apply separately with 
respect to benefits under the plan (or coverage) on 
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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 a group health plan) eliminate an 
out-of-network provider option from such plan (or 
coverage) pursuant to the terms of the plan (or cov-
erage). 
‘‘(c) PATIENT ACCESS.—A group health plan (or 
health insurance coverage offered in connection with a 
group health plan) described in subsection (a) that does 
not provide coverage for benefits outside of a network shall 
ensure that such provider network is adequate to ensure 
enrollee access to prosthetic and custom orthotic devices 
and related services provided by appropriately credentialed 
practitioners and accredited suppliers of prosthetics and 
custom orthotics. 
‘‘(d) ADDITIONAL REQUIREMENTS.— 
‘‘(1) PRIOR AUTHORIZATION.—In the case of a 
group health plan (or health insurance coverage of-
fered in connection with a group health plan) that 
requires, as a condition of coverage or payment for 
prosthetics or custom orthotics (or both) under the 
plan (or coverage), prior authorization, such prior 
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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 medical and surgical benefits provided 
under the plan (or coverage). 
‘‘(2) LIMITATION ON MANDATED BENEFITS.— 
Coverage for required benefits for prosthetics and 
custom orthotics under this section may be limited 
to coverage of the most appropriate device or compo-
nent model that meets the medical requirements of 
the patient, as determined by the treating physician 
of the patient involved. 
‘‘(3) COVERAGE
FOR
REPAIR
OR
REPLACE-
MENT.—Benefits 
for 
prosthetics 
and 
custom 
orthotics required under this section shall include 
coverage for the repair or replacement of prosthetics 
and custom orthotics, if the repair or replacement is 
due to normal wear and tear, irreparable damage, a 
change in the condition of the patient as determined 
by the treating physician, or otherwise 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 a group health 
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plan) shall not impose any annual or lifetime dollar 
limitation on benefits for prosthetics and custom 
orthotics required to be covered under this section 
unless such limitation applies in the aggregate to all 
medical and surgical benefits provided under the 
plan (or coverage) and benefits for prosthetics and 
custom orthotics. 
‘‘(e) DEFINITIONS.—In this section: 
‘‘(1) PROSTHETICS.—The term ‘prosthetics’ 
means those devices and components that 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 mastectomy 
resulting from breast cancer. 
‘‘(2) CUSTOM ORTHOTICS.—The term ‘custom 
orthotics’ 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 that 
are medically necessary for the effective use of 
the orthotic device and instructing the patient 
in the use of the device. No other patient would 
be able to use this particular orthosis. A cus-
tom-fabricated orthosis is a device which is fab-
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ricated based on clinically derived and rectified 
castings, tracings, measurements, or other im-
ages (such as x-rays) of the body part. The fab-
rication may involve using calculations, tem-
plates and component parts. This process re-
quires the use of basic materials and involves 
substantial work such as vacuum forming, cut-
ting, bending, molding, sewing, drilling and fin-
ishing prior to fitting on the patient. Custom- 
fabricated devices may be furnished only by an 
appropriately credentialed (certified or licensed) 
practitioner and accredited supplier in Orthotics 
or Prosthetics. Such devices and related serv-
ices are represented by the set of L-codes under 
the Healthcare Common Procedure Coding Sys-
tem describing this care listed on the date of 
enactment of this section in Centers for Medi-
care & Medicaid Services Transmittal 656. 
‘‘(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 
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which no other patient would be able to use, as 
well as all services and supplies that are medi-
cally necessary for the effective use of the 
orthotic device 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 
and accredited supplier in Orthotics or Pros-
thetics. Such devices and related services are 
represented by the existing set of L-codes under 
the Healthcare Common Procedure Coding Sys-
tem describing this care listed on the date of 
enactment of this section in Centers for Medi-
care & Medicaid Services Transmittal 656. 
For purposes of subparagraphs (A) and (B), Centers 
for Medicare & Medicaid Services Transmittal 656, 
upon modification or reissuance by the Centers for 
Medicare & Medicaid Services to reflect new code ad-
ditions and coding changes for prosthetics and cus-
tom orthotics, shall be the version of the Transmittal 
used for purposes of such subparagraphs. 
‘‘(3) 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 
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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. 
‘‘(f) DIFFERENTIATION FROM DURABLE MEDICAL 
EQUIPMENT.—For purposes of this section, prosthetics 
and custom orthotics shall be treated as distinct from du-
rable medical equipment.’’. 
(2) CLERICAL AMENDMENT.—The table of con-
tents in section 1 of the Employee Retirement In-
come Security Act of 1974 is amended by inserting 
after the item relating to section 714 the following: 
‘‘Sec. 716. Prosthetics and custom orthotics parity.’’. 
(b) PHSA.—Title XXVII of the Public Health Serv-
ice Act is amended by inserting after section 2728 of such 
Act (42 U.S.C. 300gg–28), as redesignated by section 
1001(2) of the Patient Protection and Affordable Care Act 
(Public Law 111–148), the following: 
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‘‘SEC. 2729. PROSTHETICS AND CUSTOM ORTHOTICS PAR-
ITY. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan (or health insurance coverage offered in connection 
with a group health plan) that provides medical and sur-
gical benefits and also provides benefits for prosthetics or 
custom orthotics (as defined under paragraphs (1) and (2) 
of subsection (e)) (or both)— 
‘‘(1) such benefits for prosthetics or custom 
orthotics (or both) under the plan (or coverage) shall 
be provided under terms and conditions that are no 
less favorable than the terms and conditions applica-
ble to substantially all medical and surgical benefits 
provided under the plan (or coverage); 
‘‘(2) such benefits for prosthetics or custom 
orthotics (or both) under the plan (or coverage) may 
not be subject to separate financial requirements (as 
defined in subsection (e)(2)) that are applicable only 
with respect to such benefits, and any financial re-
quirements applicable to such benefits shall 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 (e)(3)) applicable to such benefits for 
prosthetics or custom orthotics (or both) under the 
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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 a group health plan) that provides 
medical and surgical benefits and also provides bene-
fits for prosthetics or custom orthotics (or both), 
and that provides both in-network and out-of-net-
work benefits for prosthetics or custom orthotics (or 
both), the requirements of this section shall apply 
separately with respect to benefits 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 a group health plan) eliminate an 
out-of-network provider option from such plan (or 
coverage) pursuant to the terms of the plan (or cov-
erage). 
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‘‘(c) PATIENT ACCESS.—A group health plan (or 
health insurance coverage offered in connection with a 
group health plan) described in subsection (a) that does 
not provide coverage for benefits outside of a network shall 
ensure that such provider network is adequate to ensure 
enrollee access to prosthetic and custom orthotic devices 
and related services provided by appropriately credentialed 
practitioners and accredited suppliers of prosthetics and 
custom orthotics. 
‘‘(d) ADDITIONAL REQUIREMENTS.— 
‘‘(1) PRIOR AUTHORIZATION.—In the case of a 
group health plan (or health insurance coverage of-
fered in connection with a group health plan) that 
requires, as a condition of coverage or payment for 
prosthetics or custom orthotics (or both) under the 
plan (or coverage), prior authorization, 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 medical and surgical benefits provided 
under the plan (or coverage). 
‘‘(2) LIMITATION ON MANDATED BENEFITS.— 
Coverage for required benefits for prosthetics and 
custom orthotics under this section may be limited 
to coverage of the most appropriate device or compo-
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nent model that adequately meets the medical re-
quirements of the patient, as determined by the 
treating physician of the patient involved. 
‘‘(3) COVERAGE
FOR
REPAIR
OR
REPLACE-
MENT.—Benefits 
for 
prosthetics 
and 
custom 
orthotics required under this section shall include 
coverage for the repair or replacement of prosthetics 
and custom orthotics, if the repair or replacement is 
due to normal wear and tear, irreparable damage, a 
change in the condition of the patient as determined 
by the treating physician, or otherwise 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 a group health 
plan) shall not impose any annual or lifetime dollar 
limitation on benefits for prosthetics and custom 
orthotics required to be covered under this section 
unless such limitation applies in the aggregate to all 
medical and surgical benefits provided under the 
plan (or coverage) and benefits for prosthetics and 
custom orthotics. 
‘‘(e) DEFINITIONS.—In this section: 
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‘‘(1) PROSTHETICS.—The term ‘prosthetics’ 
means those devices and components that 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 mastectomy 
resulting from breast cancer. 
‘‘(2) CUSTOM ORTHOTICS.—The term ‘custom 
orthotics’ 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 that 
are medically necessary for the effective use of 
the orthotic device and instructing the patient 
in the use of the device. No other patient would 
be able to use this particular orthosis. A cus-
tom-fabricated orthosis is a device which is fab-
ricated based on clinically derived and rectified 
castings, tracings, measurements, or other im-
ages (such as x-rays) of the body part. The fab-
rication may involve using calculations, tem-
plates and component parts. This process re-
quires the use of basic materials and involves 
substantial work such as vacuum forming, cut-
ting, bending, molding, sewing, drilling and fin-
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ishing prior to fitting on the patient. Custom- 
fabricated devices may be furnished only by an 
appropriately credentialed (certified or licensed) 
practitioner and accredited supplier in Orthotics 
or Prosthetics. Such devices and related serv-
ices are represented by the set of L-codes under 
the Healthcare Common Procedure Coding Sys-
tem describing this care listed on the date of 
enactment of this section in Centers for Medi-
care & Medicaid Services Transmittal 656. 
‘‘(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 that are medi-
cally necessary for the effective use of the 
orthotic device 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 
and accredited supplier in Orthotics or Pros-
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thetics. Such devices and related services are 
represented by the existing set of L-codes under 
the Healthcare Common Procedure Coding Sys-
tem describing this care listed on the date of 
enactment of this section in Centers for Medi-
care & Medicaid Services Transmittal 656. 
For purposes of subparagraphs (A) and (B), Centers 
for Medicare & Medicaid Services Transmittal 656, 
upon modification or reissuance by the Centers for 
Medicare & Medicaid Services to reflect new code ad-
ditions and coding changes for prosthetics and cus-
tom orthotics, shall be the version of the Transmittal 
used for purposes of such subparagraphs. 
‘‘(3) 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. 
‘‘(4) TREATMENT
LIMITATIONS.—The term 
‘treatment limitations’ includes limits on the fre-
quency of treatment, number of visits, days of cov-
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erage, or other similar limits on the scope or dura-
tion of treatment. 
‘‘(f) DIFFERENTIATION FROM DURABLE MEDICAL 
EQUIPMENT.—For purposes of this section, prosthetics 
and custom orthotics shall be treated as distinct from du-
rable medical equipment.’’. 
(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. UPDATING STANDARD DEFINITIONS TO INCLUDE 
PROSTHETICS AND CUSTOM ORTHOTICS. 
Section 2715(g)(3) of the Public Health Service Act 
(42 U.S.C. 300gg–15(g)(3)) is amended by inserting 
‘‘prosthetics, custom orthotics,’’ after ‘‘emergency medical 
transportation,’’. 
SEC. 5. FEDERAL ADMINISTRATIVE RESPONSIBILITIES. 
(a) ASSISTANCE TO ENROLLEES.—The Secretary of 
Labor, in consultation with the Secretary of Health and 
Human Services, shall provide assistance to enrollees 
under group health plans (and health insurance coverage 
offered in connection with such plans) to which the amend-
ment made by section 3 apply with any questions or prob-
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lems with respect to compliance with the requirements of 
such amendment. 
(b) AUDITS.—The Secretary of Labor, in consulta-
tion with the Secretary of Health and Human Services, 
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 (or 
coverage) are in compliance with the amendments made 
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 the 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 prosthetics and custom orthotics on any addi-
tional cost or savings to group health plans, on State 
prosthetics and custom orthotics benefit laws, on the 
business community and the Federal Government, 
and on other issues as determined appropriate by 
the Comptroller General. 
(2) REPORT.—Not later than 2 years after the 
date of the enactment of this Act, the Comptroller 
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General of the United States shall prepare and sub-
mit to the appropriate committee 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, 
in consultation with the Secretary of Health and Human 
Services, shall promulgate final regulations to carry out 
this Act and the amendments made by this Act. 
SEC. 6. DEFINITIONS. 
In this Act: 
(1) CUSTOM ORTHOTICS AND PROSTHETICS.— 
The terms ‘‘custom orthotics’’ and ‘‘prosthetics’’ 
have the meanings given such terms in section 
716(e) of the Employee Retirement and Income Se-
curity Act of 1974 (as added by section 3). 
(2) GROUP HEALTH PLAN.—The term ‘‘group 
health plan’’ has the meaning given such term in 
section 733(a) of such Act (29 U.S.C. 1191b(a)). 
(3) HEALTH INSURANCE COVERAGE.—The term 
‘‘health insurance coverage’’ has the meaning given 
such term in section 733(b)(1) of such Act (29 
U.S.C. 1191b(b)(1)). 
Æ 
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