I 
113TH CONGRESS 
1ST SESSION H. R. 3020 
To amend the Employee Retirement Income Security Act of 1974, the Public 
Health Service Act, and the Internal Revenue Code of 1986 to provide 
parity under group and individual health plans and group and individual 
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 
AUGUST 2, 2013 
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 Committees on Education and the Workforce and 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 jurisdic-
tion of the committee concerned 
A BILL 
To amend the Employee Retirement Income Security Act 
of 1974, the Public Health Service Act, and the Internal 
Revenue Code of 1986 to provide parity under group 
and individual health plans and group and individual 
health insurance 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, 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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. 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
(5) Those experiencing limb loss and limb dys-
function can and want to regain their lives as pro-
ductive members of society, and prosthetic and 
orthotic care often enables amputees and others with 
orthopedic impairments to continue working and liv-
ing productive lives. 
(6) Insurance companies often restrict coverage 
for prosthetic and orthotic devices and related serv-
ices over an individual’s lifetime, which shifts costs 
onto individuals and consequently to the Medicare 
and Medicaid programs. 
(7) Twenty States have addressed this problem 
and have prosthetic or orthotic parity legislation, 
which also is being considered actively in other 
States. 
(8) The States in which prosthetic or orthotic 
fairness in coverage laws have been enacted have 
found there to be minimal or no increases in insur-
ance premiums and have reduced Medicare and 
Medicaid costs. 
(9) Coverage of orthotic and prosthetic devices 
and related services is only appropriate for individ-
uals missing a limb or having an orthopedic condi-
tion in need of treatment. Therefore, a fixed popu-
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
lation of individuals are candidates for these devices 
and related services. 
(10) Appropriate and timely treatment involv-
ing prosthetic and orthotic devices and related serv-
ices allow people to regain health function, pre-
existing work, and independent living. 
(11) Prosthetic and orthotic devices and related 
services are a distinct and separate benefit from the 
durable medical equipment benefit, but this distinc-
tion often is not recognized as insurers typically 
combine these benefits under a combined limit. 
(12) The Patient Protection and Affordable 
Care Act (Public Law 111–148) and the Health 
Care and Education Reconciliation Act (Public Law 
111–152), include rehabilitative and habilitative 
services as an essential health benefit, which legisla-
tive history shows is intended to cover prosthetic and 
orthotic devices and related services. 
(13) The Institute of Medicine concluded that 
prosthetic and orthotic devices and related services 
are covered under a typical employer plan. 
(14) However, while lifetime and annual dollar 
limitations on essential health benefits are prohibited 
under the Patient Protection and Affordable Care 
Act (Public Law 111–148) and the Health Care and 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
Education Reconciliation Act (Public Law 111–152), 
other techniques to minimize or eliminate coverage 
continue to be used across the country and are deny-
ing individuals access to medically necessary pros-
thetic and orthotic devices and related services. 
(b) PURPOSE.—It is the purpose of this Act to re-
quire that each group and individual health plan and indi-
vidual and group health insurance coverage that provides 
medical and surgical benefits and also provides coverage 
for prosthetics or custom orthotics (or both), provide such 
coverage under terms and conditions that are no less fa-
vorable than the terms and conditions under which med-
ical and surgical benefits are provided under such plan. 
SEC. 3. PROSTHETICS AND CUSTOM ORTHOTICS FAIRNESS 
IN COVERAGE. 
(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 FAIR-
NESS IN COVERAGE. 
‘‘(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-
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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 (d)(3)) 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 (d)(4)) 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). 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
‘‘(b) 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. 
‘‘(c) 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 BENEFITS.—Coverage for 
required 
benefits 
for 
prosthetics 
and 
custom 
orthotics under this section may be limited to cov-
erage of the most appropriate device or component 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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. 
‘‘(d) 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 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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-
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. 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
‘‘(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-
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-
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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. 
‘‘(4) TREATMENT
LIMITATIONS.—The term 
‘treatment limitations’ includes limits on the fre-
quency of treatment, number of visits, specific pre-
scribed components, limits that are more broadly ap-
plicable to durable medical equipment, or other simi-
lar limits on the amount, duration, or scope of treat-
ment. 
‘‘(e) 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. 715. Additional market reforms. 
‘‘Sec. 716. Prosthetics and custom orthotics parity.’’. 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6211
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
(b) PHSA.— 
(1) IN GENERAL.—Title XXVII of the Public 
Health Service 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 Pro-
tection and Affordable Care Act (Public Law 111– 
148), the following: 
‘‘SEC. 2729. PROSTHETICS AND CUSTOM ORTHOTICS PAR-
ITY. 
‘‘(a) IN GENERAL.—In the case of a group health 
plan, or a health insurance issuer offering group or indi-
vidual health insurance coverage, that provides medical 
and surgical benefits and also provides benefits for pros-
thetics 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 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00012
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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) PATIENT ACCESS.—A group health plan, or 
health insurance issuer offering group or individual health 
insurance coverage, 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. 
‘‘(c) ADDITIONAL REQUIREMENTS.— 
‘‘(1) PRIOR AUTHORIZATION.—In the case of a 
group health plan, or health insurance issuer offer-
ing group or individual health insurance coverage, 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00013
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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 cov-
erage as a condition of coverage or payment for all 
similar medical and surgical benefits provided under 
the plan or coverage. 
‘‘(2) LIMITATION ON BENEFITS.—Coverage for 
required 
benefits 
for 
prosthetics 
and 
custom 
orthotics under this section may be limited to cov-
erage of the most appropriate device or component 
model that adequately meets the medical require-
ments 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. 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00014
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
‘‘(d) 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-
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-
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00015
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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 
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 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00016
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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 
participant or beneficiary with respect to benefits 
under the plan or health insurance coverage. 
‘‘(4) TREATMENT
LIMITATIONS.—The term 
‘treatment limitations’ includes limits on the fre-
quency of treatment, number of visits, specific pre-
scribed components, and limits that are more broad-
ly applicable to durable medical equipment, or other 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
similar limits on the amount, duration, or scope of 
treatment. 
‘‘(e) 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) APPLICATION TO INDIVIDUAL HEALTH IN-
SURANCE COVERAGE BEFORE 2014.—For purposes of 
applying section 2729 of the Public Health Service 
Act, as inserted by paragraph (1), to individual 
health insurance coverage before 2014, the provi-
sions of such section shall be treated as also in-
cluded under part B of title XXVII of the Public 
Health Service Act. 
(c) INTERNAL REVENUE CODE.—Subchapter B of 
chapter 100 of subtitle K of the Internal Revenue Code 
of 1986 is amended by adding after section 9813 the fol-
lowing: 
‘‘SEC. 9814. PROSTHETICS AND CUSTOM ORTHOTICS FAIR-
NESS IN COVERAGE. 
‘‘(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 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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 
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). 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00019
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
‘‘(b) 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. 
‘‘(c) 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 BENEFITS.—Coverage for 
required 
benefits 
for 
prosthetics 
and 
custom 
orthotics under this section may be limited to cov-
erage of the most appropriate device or component 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00020
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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) ASSISTANCE
TO
ENROLLEES.—The Sec-
retary of the Treasury, in consultation with the Sec-
retary of Health and Human Services, shall provide 
assistance to enrollees under plans or coverage to 
which the amendment made by section 3 apply with 
any questions or problems with respect to compli-
ance with the requirements of such amendment. 
‘‘(5) AUDITS.—The Secretary of the Treasury, 
in consultation with the Secretary of Health and 
Human Services, shall provide for the conduct of 
random audits of group health plans (and health in-
surance coverage offered in connection with such 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00021
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
plans) to ensure that such plans (or coverage) are in 
compliance with the amendments made by section 
(3). 
‘‘(d) 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-
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-
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00022
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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 
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 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00023
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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 
participant or beneficiary with respect to benefits 
under the plan or health insurance coverage. 
‘‘(4) TREATMENT
LIMITATIONS.—The term 
‘treatment limitations’ includes limits on the fre-
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00024
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
quency of treatment, number of visits, specific pre-
scribed components, or other similar limits on the 
scope or duration of treatment. 
‘‘(e) DIFFERENTIATION FROM DURABLE MEDICAL 
EQUIPMENT.—For purposes of this section, prosthetics 
and custom orthotics shall be treated as distinct from du-
rable medical equipment.’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply with respect to plan years begin-
ning on or after the date of the enactment of this section 
and with respect to health insurance coverage issued on 
or after such date. 
SEC. 4. UPDATING STANDARD DEFINITIONS TO INCLUDE 
PROSTHETICS AND CUSTOM ORTHOTICS. 
(a) IN GENERAL.—Section 2715(g)(3) of the Public 
Health Service Act (42 U.S.C. 300gg–15(g)(3)) is amend-
ed by inserting ‘‘prosthetics, custom orthotics,’’ after 
‘‘emergency medical transportation,’’. 
(b) PROSTHETICS; CUSTOM ORTHOTICS.—In devel-
oping standards for the definitions of the terms ‘‘pros-
thetics’’ and ‘‘custom orthotics’’ pursuant to the amend-
ment made by subsection (a), the Secretary shall ensure 
that such definitions are consistent with the definitions of 
such terms in section 2729(d) of the Public Health Service 
Act (as added by section 3(b) of this Act). 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00025
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
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-
ments made by section 3 apply with any questions or prob-
lems with respect to compliance with the requirements of 
such amendments. 
(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) 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. 
(d) DEFINITIONS.—In this section: 
(1) GROUP HEALTH PLAN.—The term ‘‘group 
health plan’’ has the meaning given such term in 
section 733(a) of the Employee Retirement and In-
come Security Act of 1974 (29 U.S.C. 1191b(a)). 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00026
Fmt 6652
Sfmt 6201
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS
(2) 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 
VerDate Mar 15 2010 
00:47 Aug 10, 2013
Jkt 029200
PO 00000
Frm 00027
Fmt 6652
Sfmt 6301
E:\BILLS\H3020.IH
H3020
jbell on DSK7SPTVN1PROD with BILLS