AB 1121

This bill requires health insurance policies and self-insured governmental health plans to provide coverage of prosthetic limbs and custom orthotic braces (devices) when medically necessary for an individual to participate in activities of daily living or essential job-related activities or to perform physical activities for maximizing limb function, or to meet the individual’s medical needs for purposes of showering or bathing.

The bill specifies that coverage must include the materials, components, and related services necessary to use a device for its intended purpose; any instruction provided to the individual on using the device; and the reasonable repair of the device. The bill also requires coverage of more significant repairs or replacement of the device, without regard to continuous use or useful lifetime restrictions, when medically necessary due to a change in the individual’s physiological condition or an irreparable change in the device’s condition or if the cost to repair the device exceeds 60 percent of the device’s replacement cost.

The bill requires that the coverage must be, at a minimum, equal to the coverage and payment for prosthetic and orthotic devices provided under the federal Medicare program.

The bill provides that the coverage may only be subject to the cost-sharing provisions that apply generally to the coverage provided under the policy or plan for inpatient physician and surgical services. The bill also requires that a managed care plan must ensure access to medically necessary clinical care and the devices from at least two in-network providers in this state. If the care and services are not available from an in-network provider, the managed care plan must provide a process to refer an individual to an out-of-network provider and must fully reimburse that provider at a mutually agreed upon rate.

This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.