Amendment vs bill House Committee Amendment, #3272, INS, Draft vs HB477 Original

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HLS 26RS-846 ORIGINAL Regular Session HOUSE BILL NO.
HCAHB477 4902 3272 HOUSE COMMITTEE AMENDMENTS Regular Session Substitute for Original House Bill No.
477 BY REPRESENTATIVE HEBERT INSURANCE/HEALTH:
477 by Representative Hebert as proposed by the House Committee on Insurance This document reflects the content of a substitute bill but is not in a bill form;
Modifies provisions of law regarding health insurance coverage of prosthetic and custom orthotic devices and services AN ACT To enact R.S.
page numbers in this document DO NOT correspond to page numbers in the substitute bill itself.
22:1049.1 and Part IX of Chapter 5-E of Title 40 of the Louisiana Revised Statutes of 1950, to be comprised of R.S.
To amend and reenact R.S.
40:1259.11, and to repeal R.S.
22:1049 and to enact Part IX of Chapter 5-E of Title 40 of the Louisiana Revised Statutes of 1950, to be comprised of R.S.
22:1049, relative to health insurance;
40:1259.11, relative to health insurance;
to require coverage for prosthetic and custom orthotic devices and associated services;
to require coverage for prosthetic and orthotic devices and associated services;
to delineate coverage standards, encompassing multiple devices, materials, components, repair, and replacement;
to delineate coverage standards, encompassing multiple devices, materials, components,repair,andreplacement;toproviderequirementsforpriorauthorization and cost-sharing;
to provide requirements for prior authorization and cost-sharing;
to provide for network adequacy standards;
to provide for network adequacystandards;
22:1049.1 is hereby enacted to read as follows:
22:1049 is hereby amended and reenacted to read as follows:
§1049.1.
§1049.
Coverage for prosthetic and custom orthotic devices and services A.
Requirement for coverage of prosthetic and orthotic devices and prosthetic services A.
As used in this Section:
Notwithstanding the provisions of R.S.
(1) "Accreditedfacility"meansanyentitythatisaccreditedbytheAmerican Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABCop) or bythe Board for Orthotist/Prosthetist Certification (BOC) and that provides prosthetic devices or prosthetic services.
22:1047 to the contrary, anyAny health coverage plan specified in Subsection H J of this Section which is issued for delivery, delivered, renewed, or otherwise contracted for in this state on or after January 1, 2009, shall provide coverage of prosthetic and orthotic devices and prosthetic and orthotic services as further provided in this Section.
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B.
Eligibility and limits of coverage for prosthetic and orthotic devices and prosthetic services shall be determined by the health coverage plan in consultation with the enrollee's medical providers and their assessment of based on medical necessity.
In determining medical necessity, the health coverage plan shall consider therecommendationsbytheinsured'sphysicianoradvancedpracticeprovider.
Such recommendations shall be based on the most appropriate prosthesis or orthosis that Page 1 of 9 CODING:
HLS 26RS-846 ORIGINAL HB NO.
HCAHB477 4902 3272 adequately meets the medical needs of the insured to restore or maintain the ability to perform activities of daily living and essential job-related functions.
477 (2) "Advanced practice provider" means a healthcare professional who is licensed in this state and authorized under state law to evaluate patients and to prescribe orthotic and prosthetic devices within the provider's scope of practice.
Such coverage shall, at a minimum, equal the coverage and prevailing payment rate for prosthetic and orthotic devices provided under federal laws and regulations for the aged and disabled pursuant to 42 United States Code, Sections 1395k, 1395l and 1395mand42CodeofFederalRegulations,Sections414.202,414.210,414.228and 410.100.
(3) "Health coverage plan" means any hospital, health, or medical expense insurancepolicy,hospitalormedicalservicecontract,employeewelfarebenefitplan, contractoragreementwithahealthmaintenanceorganizationorapreferredprovider organization, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan and the Office of Group Benefits programs.
In accordance with Subsection C of this Section covered benefits shall be provided for more than one prosthesis or orthosis when determined by the health coverage plan to be medically necessaryand may not exclude coverage for orthotic or prosthetic devices designed for physical activity or showering and bathing pursuant to blanket exclusions of items used for "recreation or leisure", "athletic or sportspurposes", or"luxuryorconvenience".
(4) "Prosthetic device" or "prosthesis" means an artificial limb designed to maximize function, stability, and safety of the patient.
Anydenialorlimitofcoveragebased on lack of medical necessitymaybe appealedin accordancewith R.S.
The term does not include artificial eyes, ears, noses, dental appliances, ostomy products, or devices such as eyelashes or wigs.
22:1121 R.S.
(5) "Prosthetic services" means the science and practice of evaluating, measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or servicing of a prosthesis through the replacement of external parts of a human body lost due to amputation or congenital deformities to restore function, cosmesis, or both.
22:1241 et seq.
It also includes any medically necessary clinical care.
and R.S.
(6) "Orthosis" means a custom-designed, custom-fabricated, custom-fitted, pre-fabricated, or modified device to treat a neuromusculoskeletal disorder or acquired condition.
22:2431, et seq.
(7) "Orthotic services" means the science and practice of evaluating, measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or servicingacustomorthosis.
and with respect to claim denials based on medical necessity, such denials shall be in writing and include clear reasoning and descriptions of how and why the request or claim does not meet medical necessity standards.
Prosthetists,orthoticassistants,andorthoticfitterswho are credentialed by a nationally recognized Orthotic, Prosthetic and Pedorthic certifying board or are licensed, if applicable, may be privileged based on written objective criteria to provide orthotic care.
Such medical necessity determination shall consider information and recommendation from the treating physician in consultation with the insured, includingbutnotlimitedtoinformationinthemedicalrecordofthetreatingorthotist or prosthetist, and the results of a functional limit test assessment.
Certified or licensed pedorthists may be privileged based on written objective criteria to provide lower extremity orthotic care.
Such test assessment shall consider but not be limited to the following factors:
(1) The insured's past history, including prior use of prosthetic or orthotic devices if applicable.
(2) The insured's current condition, including the status of the residual limb and the nature of other medical problems.
(3) The insured's desire to ambulate, with respect to lower limb prosthetic devices, or maximize upper limb function, with respect to upper limb prosthetic devices, and the insured's desire and ability to use an orthosis or prosthesis to maintain maximum function.
HLS 26RS-846 ORIGINAL HB NO.
HCAHB477 4902 3272 C.
477 B.
(1) In addition to the primaryprostheticororthoticdeviceoftheupperor lower extremity, the health coverage plan shall provide coverage for an additional upper or lower extremity prosthetic or orthotic device when:
Any health coverage plan specified in Subsection P of this Section that isdelivered,issuedfordelivery,renewed,orotherwisecontractedforinthisstateon or after January 1, 2027, shall provide coverage for prosthetic and custom orthotic devices and services.
(a) The treating physician or other advanced practice provider determines thattheadditionalprosthesisororthosisisnecessarytoenabletheenrolleetoengage in physical activities, as applicable, such as running, biking, swimming, strength training, showering, bathing, and to maximize the enrollee's whole-bodyhealth and lower and upper limb function.
At a minimum, such coverage shall equal the coverage and prevailing payment rates for prosthetic and orthotic devices provided under federal laws and regulations for older adults and persons with disabilities pursuant to 42 U.S.C.
(b) The single additional prosthetic or orthotic device is determined to be medicallynecessarybythehealthcoverageplanasbeingthemostappropriatedevice to meet the insured's medical needs for purposes of performing physical activities such as running, biking, swimming, strength training, and other similar activities.
1395k, 1395l, and 1395m and 42 CFR 414.202, 414.210, 414.228, and 410.100.
(c) This Subsection does not require coverage for a replacement of the additional prosthetic or orthotic device of the upper or lower extremity unless determined bythe health coverage plan, in consultation with the enrollee's medical providers, to be medically necessary.
Coveredbenefitsshallbeprovidedformorethanoneprosthesisororthosis when medically necessary as further provided in this Section.
(2) If neither the original prosthetic or orthotic devices described in Subsection B nor the additional upper or lower extremity prosthetic or orthotic deviceprovidedinParagraph(C)(1)ofthisSectionissufficienttoenabletheinsured to safelyengagein bathingandshowering,theninadditiontothosedevices,asingle additional prosthetic or orthotic device recommended bythe insured's physician or other advanced practice provider for purposes of showering or bathing shall be covered when determined to be medicallynecessaryto enable the enrollee to safely engage in those activities.
C.
C.D.
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Eligibilityforprostheticandcustomorthoticdevicesandservicesisbased on medical necessity as determined by the enrollee's physician or other advanced practice provider.
A health coverage plan may require prior authorization for prosthetic and orthotic devices and prosthetic services in the same manner that prior authorization is required for any other covered benefit, if such procedures are rendered in a nondiscriminatory manner.
Medical necessity includes the most appropriate prosthesis or custom orthosis thatadequatelymeetsthemedicalneedsoftheenrolleetorestoreor maintain the ability to perform activities of daily living and essential job-related functions.
Utilization review procedures shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or custom orthotics, solely on the basis of an insured's actual or perceived disability.
D.
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In addition to the device required pursuant to Subsection B of this Section, a prosthetic or custom orthotic device determined by the enrollee's prosthetic or orthotic care provider to be the most appropriate device to meet the enrollee'smedicalneedsforpurposesofperformingphysicalactivitiesincludingbut not limited to running, biking, swimming, and strength training, shall be covered whenthetreatingphysicianorotheradvancedpracticeproviderdeterminesthatsuch device is necessary to enable the enrollee to engage in physical activity and to maximize whole-body health and lower or upper limb function.
E.
InadditiontothedevicesrequiredpursuanttoSubsectionsBandCofthis Section, a prosthetic or custom orthotic device determined by the enrollee's prosthetic or orthotic care provider to be the most appropriate device to meet the enrollee'smedicalneedsforpurposesofshoweringorbathingshallbecoveredwhen the treating physician or other advanced practice provider determines that such Page 3 of 9 CODING:
HLS 26RS-846 ORIGINAL HB NO.
HCAHB477 4902 3272 An insurer shall not deny a prosthetic or custom-orthotic benefit for an individual with limb loss, limb absence, or limb impairment that would otherwise be covered for a non-disabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
477 deviceis necessaryto enable the enrollee to safelyengage in bathingand showering and to maintain whole-body health and lower or upper-limb function.
D.E.
F.
A health coverage plan may impose co-payments, deductibles, or coinsuranceamountsonprostheticandorthoticdevicesandprostheticservices.
Coverage required bythis Section includes all materials and components necessary for the use of prosthetic and custom orthotic devices.
The co-payments shall not be greater than the co-payments that apply to other benefits under the plan.
The repair and replacement of prosthetic devices also shall be covered subject to co-payments, coinsurance, and deductibles that are no more restrictive than the co-payments, coinsurance, and deductibles that apply to other benefits under the plan, unless necessitated bymisuse or loss.
F.(1) Therepairandreplacementofprostheticandorthoticdevicesalsoshall be covered subject to co-payments, coinsurance, and deductibles that are no more restrictive than the co-payments, coinsurance, and deductibles that apply to other benefits under the plan, unless necessitated bymisuse theft or loss.
(2) Coverage of repair or replacement of prosthetic and orthotic devices, subject to coverage as outlined in Subsection B, of this Section shall meet medical necessity requirements of the health coverage plan, and be recommended by the treating healthcare provider.
(3) Thetreatinghealthcareprovidermayrecommendthatreplacementofthe device is required if anyof the following apply:
(a) There is a change in the physiological condition of the enrollee.
(b) There is an irreparable change in the condition of the device or any component of the device.
(c) The condition of the device requires repairs that are too extensive to be cost effective in accordance with the health coverage plan's guidelines.
Coverage required bythis Section includes instruction to the enrollee on the proper use of the prosthetic or custom orthotic device.
A health plan that provides coverage for prostheses or orthoses shall ensure access to medically necessary clinical care and to prostheses and custom orthoses from not less than two distinct prosthetic and orthotic providers in the managedcareplan'sprovidernetworklocatedinthestate.Intheeventthatmedically Page 4 of 9 CODING:
H.
Wordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored are additions.
Coverage requiredbythis Sectionincludesmedicallynecessaryrepair or replacement of a prosthetic or custom orthotic device.
HCAHB477 4902 3272 necessary covered orthoses and prostheses are not available from an in-network provider, the insurer shall provide processesto refera member to anout-of-network provider and shall fullyreimburse the out-of-network provider at a mutually agreed upon rate less member cost sharing determined on an in-network basis.
Payment shall be made for the replacement of a device or any part thereof, without regard to continuous use or useful lifetime restrictions, when an ordering healthcare provider determines that replacement is necessarydue to any of the following:
E.H.
(1) A change in the physiological condition of the enrollee.
A health coverage plan shall include a requirement that prosthetic devices be provided by an accredited facility and a requirement that prosthetic servicesbeprescribedbyalicensedphysicianandprovidedbyanaccreditedfacility.
(2) An irreparable change in the condition of the device or a part of the device.
F.I.
(3) The condition of the device or part requires repairs, and the cost of such repairs would exceed sixty percent of the cost of a replacement device or part.
Coverage of prosthetic andorthoticdevicesandprostheticservicesmay be made subject to but no more restrictive than the provisions of a health coverage plan that apply to other benefits under the plan.
I.
An individual health plan that is delivered, issued for delivery, or renewed in this state that covers prostheses and custom orthoses shall consider these benefits rehabilitative and habilitative services anddevicesforpurposesofanystateorfederalrequirementforcoverageofessential health benefits.
A health coverage plan may require confirmation from the prescribing healthcareprovideriftheprostheticorcustom orthoticdeviceorpartbeingreplaced is less than three years old.
G.(1) A health coverage plan mayapply an annual limit of benefits payable under this Section of no less than fifty thousand dollars per limb.
(2) This Subsection does not prohibit a health benefit plan from providing coveragethatis greaterormorefavorabletoaninsuredthantherequirementsofthis Subsection.
(3) An insured maychoose a prosthetic device that is priced higher than the benefitpayableunderthehealthbenefitplanandmaypaythedifferencebetweenthe price of the device and the benefit payable, without financial or contractual penalty to the provider of the device.
Ahealthcoverageplanthatcoversprostheticand custom orthoticdevices shall include in its evidence of coverage a description of the insured's rights under this Section.
A health coverage plan subject to this Section shall report to the commissioner on its experience pursuant to this Section for plan years 2027-2028.
Anydenial of coverage based on medical necessityshall be in writing and shall include clear reasoning and an explanation of how the request does not meet medical necessity standards.
The report shall be in a form prescribed by the commissioner and shall include the number of claims and the total amount of claims paid in this state for the services requiredunderthisSection.
Any denial or limit of coverage based on a lack of medical necessity may be appealed in accordance with R.S.
Thecommissionershallaggregatethisdatabyplanyear in a report and submit the report to the House and Senate committees on insurance no later than July 1, 2029.
22:3070 et seq.
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Medical necessitydeterminations shall consider information and recommendations from the treating physician in consultation with the enrollee, including information in the medical record of the treating orthotist or prosthetist and the results of a functionalassessment.
Suchassessmentshallconsiderbutnotbelimitedtoallofthe following:
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HLS 26RS-846 ORIGINAL HB NO.
HCAHB477 4902 3272 HK.
477 (1) The insured's past history, including prior use of prosthetic or orthotic devices if applicable.
As used in the Section:
(2) Theinsured'scurrentcondition, includingthestatus oftheresiduallimb.
(1) "Accreditedfacility"meansanyentitythatisaccreditedbytheAmerican Board for Certification in Orthotics Prosthetics and Pedorthics (ABC) or by the Board for Orthotist/Prosthetist Certification (BOC) and that provides prosthetic devices or prosthetic services.
(3) The insured's desire to ambulate with respect to lower limb prosthetic devices,maximizeupperlimbfunctionwithrespecttoupperlimbprostheticdevices, andtheinsured'sdesireandabilitytouseanorthosis to maintainfunctionalabilities.
(2) "Advanced practice provider" means a healthcare professional who is licensedinthisstateandauthorizedunderstatelawtoevaluatepatientsandprescribe prosthetic and orthotic devices within the provider's scope of practice.
K.
(2)(3) "Health coverage plan" shall mean any hospital, health, or medical expense insurance policy, hospital or medical service contract, employee welfare benefit plan, contract or agreement with a health maintenance organization or a preferred provider organization, health and accident insurance policy, or any other insurance contract of this type, including a group insurance plan and the Office of Group Benefits programs.
An individual health plan delivered, issued for delivery, or renewed in this state that covers prosthetic and custom orthotic devices shall consider these benefitsrehabilitativeandhabilitative servicesanddevicesforpurposesofanystate or federal requirement for coverage of essential health benefits.
(4) "Orthotic device" or "Orthosis" means a custom-designed, custom-fabricated,custom-fitted,ormodifieddevicetotreataneuromusculoskeletal disorder or acquired condition.
L.
For purposes of this Section, orthosis shall be limited to devices utilized for the upper or lower limbs.
A health coverage planmayrequirepriorauthorizationforprostheticand custom orthotic devices and services in the same manner as other covered benefits, if such procedures are applied in a nondiscriminatory manner.
(5) "Orthotic services" means the science and practice of evaluating, measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or servicingacustom orthosis.
Utilization review procedures shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or custom orthotics, solely on the basis of an insured's actual or perceived disability.
Prosthetists, orthoticassistants, andorthoticfitterswho are credentialed by a nationally recognized Orthotic, Prosthetic and Pedorthic certifying board or are licensed, if applicable, may be privileged based on written objective criteria to provide orthotic care.
M.
Certified or licensed pedorthists may be privileged based on written objective criteria to provide lower extremity orthotic care.
A health coverage plan may impose co-payments, deductibles, or coinsurance amounts on prosthetic and custom orthotic devices and services.
(3)(6) "Prosthetic device" or "prosthesis" means an artificial limb designed to maximize function, stability, and safety of the patient.
Such cost-sharing shall not be greater than that applied to other benefits under the plan.
Prosthetic device or prosthesisalsomeansanartificialmedicaldevicethatisnotsurgicallyimplantedand Page 6 of 9 CODING:
Repair and replacement of prosthetic and custom orthotic devices shall be covered subject to cost-sharing that is no more restrictive than that applied to other benefits, unless necessitated by theft or loss.
N.
A health coverage plan shall require that prosthetic and custom orthotic devices be provided by an accredited facility.
The prescription for such prosthetic and custom orthotic services shall be issued by a licensed physician, and the provision of these services shall occur at an accredited facility.
O.
Coverage required in accordancewith this Section shall be aligned with, and not more restrictive than, the provisions applicable to other benefits within the health coverage plan.
An insurer shall not deny a prosthetic or custom orthotic benefit to an individual with limb loss, limb absence, or limb impairment if such Page 5 of 9 CODING:
HLS 26RS-846 ORIGINAL HB NO.
HCAHB477 4902 3272 thatisusedtoreplaceamissinglimb.
477 benefits would otherwise be available to a non-disabled individual seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
Thetermdoesnotincludeartificialeyes,ears, noses, dental appliances, ostomy products, or devices such as eyelashes or wigs.
P.
(4)(7) "Prosthetic services" means the science and practice of evaluating, measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or servicing of a prosthesis through the replacement of external parts of a human body lost due to amputation or congenital deformities to restore function, cosmesis, or both.
A health coverage plan that provides coverage for prosthetic and custom orthotic services shall ensure access to medically necessary clinical care for prosthetic and custom orthotic devices and technology.
It shall also include any medically necessary clinical care.
There shall be a minimum oftwodistinctprostheticandcustomorthoticserviceproviderswithinthisstatewho are also part of the plan's authorized provider network.
IK.
If medically necessary covered orthotic or prosthetic devices or services are not available from an in- network provider, the insurer shall establish and maintain a process to refer the enrollee to an out-of-network provider.
The provisions of this Section shall not apply to limited benefit health insurance or short-term policies or contracts.
The insurer shall reimburse that provider at a mutually agreed-upon rate, reduced only bythe member's cost-sharing that would apply if the service were obtained from an in-network provider.
Q.
Each carrier that issues a health plan subject to this Section shall report to the commissioner of insurance on its experience pursuant to this Section for plan years 2027-2028.
The report shall be in a form prescribed by the commissioner of insuranceandshallincludethenumberofclaimsandthetotalamountofclaimspaid inthisstatefortheservicesrequiredbythisSection.
Thecommissionerofinsurance shall aggregate this data by plan year in a report and submit the report to the House and Senate committees on insurance.
R.
The provisions of this Section do not apply to limited benefit health insurance policies or contracts.
The Louisiana Medicaid program shall provide coverage for prosthetic and custom orthotic devices and services to an enrollee when such devices or Page 6 of 9 CODING:
The Louisiana Medicaid program shall provide coverage for prosthetic and custom orthotic devices and services to an enrollee when such devices or services are deemed medically necessary in accordance with the standards and clinical criteria set forth bythe Medicaid program.
Wordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored are additions.
HLS 26RS-846 ORIGINAL HB NO.
477 services are deemed medically necessary in accordance with the standards and clinical criteria set forth bythe Medicaid program.
Coverage includes the devices, services, materials, components, instruction, repair, and replacement as delineated in R.S.
Coverage includes the devices, services, materials, components, instruction, repair,and replacementas delineated in R.S.
22:1049.1, including but notlimitedtoservicesrequiredtorestoreormaintaintheabilitytoperformactivities of daily living, essential job-related functions, and medically necessary physical activity.
22:1049, includingbut not limited to services required to restore or maintain the abilityto perform activities of daily living, essential job-related functions, and medically necessary physical activity.
22:1049.1 applyto this Section unless the context clearly requires otherwise.
22:1049 apply to this Section unless the context clearly requires otherwise.
(2) Promulgate all necessary rules and regulation in accordance with the Administrative Procedure Act.
(2) Promulgate all necessary rules and regulations in accordance with the Administrative Procedure Act.
(3) Take any other actions necessary to implement the provisions of this Chapter.
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Wordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored are additions.
HCAHB477 4902 3272 (3) Take any other actions necessary to implement the provisions of this Chapter.
R.S.
The coverage requirements provided by the provisions of this Act as enacted by Section 1 of this Act shall apply to any new health coverage plan delivered, issued for delivery or otherwise contracted for in this state beginning on or after January1, 2027.
22:1049 is hereby repealed in its entirety.
Anyhealth coverage policy, contract, or plan in effect prior to January1, 2027, shall convert to conform to the provisions of Section 1 of this Act upon renewal, on or beforethe renewal date, but no later than January 1, 2028.
Section4.
Section 4.
Thecoveragerequirementsprovided bytheprovisions ofR.S.
The report requiredto be compiled and submitted to the commissioner of insurance as required by the provisions of R.S.
22:1049.1 as enacted bySection 1 of this Act shall applyto anyhealth coverage plan delivered, issued for delivery, renewed, or otherwise contracted for in this state beginning January 1, 2027.
22:1049(J) as enacted by Section 1 of this Act shall be due beginning July 1, 2029.
The report required to be compiled and submitted to the commissioner of insurance as required by the provisions of R.S.
This Act shall become effective upon signature bythe governor or, if not signedbythegovernor,uponexpirationofthetimeforbillstobecomelawwithoutsignature by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana.
22:1409.1(Q) as enacted by Section 1 of this Act shall be due beginning July 1, 2029.
Section 6.
This Act shall become effectiveupon signature bythe governor or, if not signedbythegovernor,uponexpirationofthetimeforbillstobecomelawwithoutsignature by the governor, as provided byArticle III, Section 18 of the Constitution of Louisiana.
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DIGEST ThedigestprintedbelowwaspreparedbyHouseLegislative Services.
Wordsinstruckthroughtypearedeletionsfromexistinglaw;wordsunderscored are additions.
HLS 26RS-846 ORIGINAL HB NO.
477 DIGEST ThedigestprintedbelowwaspreparedbyHouseLegislative Services.
1:13(B) and 24:177(E)] HB 477 Original 2026 Regular Session Hebert Abstract:
1:13(B) and 24:177(E)] HB Draft 2026 Regular Session Abstract:
Mandates that health coverage plans provide comprehensive coverage for prosthetic and custom orthotic devices and associated services.
Modifies the requirements for health insurance coverage of prosthetic and customorthoticdevicesandservices.Specifiesmedicalnecessitystandards,expands coverage for additional devices, and sets guidelines for prior authorization, repair and replacement services, and network access.
This includes coverage for multiple devices, materials and components, instructional support, repairsandreplacementswhendeemedmedicallynecessary.
Establishes annual benefit limits, outlines reporting requirements, and definitions.
Outlines protocols for medical necessity determinations, prior authorization processes, cost-sharing obligations, nondiscrimination provisions, network adequacy standards, relevant definitions, and reporting requirements.
Mandates Medicaid coverage for prosthetic and custom orthotic devices and services.
Excludes limited benefit health insurance policies or contracts.
Presentlawmandatesthathealthcoverageplansprovidecoverageforprostheticandorthotic devicesandservices.Itestablishesguidelinesformedicalnecessity,cost-sharing,repairand replacement, prior authorization, and provider accreditation.
Establishes Medicaid coverage for prosthetic and custom orthotic devices and associated services.
Additionally, it defines key terms while outlining limitations and exceptions.
Present law requires health coverage plans to provide coverage for prosthetic and orthotic devices.
Proposed law modifies medical necessity determinations to ensure consideration of recommendationsfromthetreatingphysicianoradvancedpracticeprovider,aswellasinput fromthetreatingorthotistorprosthetist, includingtheoutcomesofafunctionalassessment.
Defines "accredited facility", "health coverage plan", "prosthetic device", and "prostheticservices".
Proposed law requires that coverage be at least equivalent to the prevailing Medicare payment rate for prosthetic and orthotic devices.
Presentlawspecifiesthatdevicesbedeemedmedicallynecessaryand prescribed by a licensed physician.
Furthermore, it mandates coverage for an Page 8 of 9 CODING:
Present law authorizes health coverage plans to apply standard utilization review procedures and cost-sharing requirements to benefits.
Provides thatcoverageforprostheticandorthoticdevicesbesubjecttothesametermsandconditions applicable to other medical and surgical benefits under the plan.
Proposed law repealspresent law (R.S.
22:1049) and enacts proposed law (R.S.
22:1049.1) to require health coverage plans delivered, issued for delivery, renewed, or otherwise contracted for in La.
on or after Jan.
1, 2027, to provide comprehensive coverage for prosthetic and custom orthotic devices and services.
Proposed law mandates that coverage beatleastequaltoMedicarecoverageandpaymentratesfordevicesandservices.
Proposed law ensures that multiple devices are covered when medicallynecessary.
Proposed law stipulates that eligibility for prosthetic and custom orthotic devices and services be based on medical necessity at the discretion of the treating physicians and practicing providers.
Requires coverage for additional devices, materials, components, instructions, and the repair or replacement of devices when deemed medicallynecessary.
Proposed law mandates that health coverage plans incorporate a description outlining the rights of the insured in the evidence of coverage.
Present law requires that insurers issue clear and reasonable written denials of coverage.
Proposed law establishes standards for medical necessity determinations and appeals.
Requiresthatbenefitsbetreatedasrehabilitativeandhabilitativeservicesforessentialhealth benefits purposes.
Proposed law creates prior authorization procedures if applied in a nondiscriminatory manner.
Prohibits denial of habilitative or rehabilitative benefits on the basis of disability.
Authorizescost-sharingbutprohibitscost-sharingrequirementsthataremorerestrictivethan those applied to other benefits.
Proposed law requires prosthetic and custom orthotic devices to be provided by an accredited facility and prescribed by a licensed physician.
Prohibits insurers from implementing more restrictive standards for benefits compared to other benefits.
Proposed law prevents the denial of benefits to individuals with limb loss or limb impairment when comparable benefits are accessible to non-disabled individuals.
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HLS 26RS-846 ORIGINAL HB NO.
HCAHB477 4902 3272 additionalupperorlowerextremityprostheticororthoticdevice,whenmedicallynecessary for physical activity, bathing, showering, or whole-body health.
477 Proposedlaw requireshealthcoverageplanstoensureaccesstomedicallynecessaryclinical care and to maintain a network that includes at least two prosthetic and orthotic service providers.
Proposed law stipulates coverage for a separate bathing or showering device when neither the primary nor additional device facilitates safe bathing.
Requires referral to and reimbursement of out-of-network providers when medically necessary services are unavailable in-network.
Proposed law permits prior authorization but forbids the denial of habilitative or rehabilitativebenefitssolelybasedonactualorperceiveddisability.
Proposed law defines “accredited facility”, "advanced practice provider", “health coverage plan”, “prosthetic device”, “prosthetic services”, “orthosis”, and “orthotic services”.
Proposedlawprohibits the denial of prosthetic or custom-orthotic benefits to individuals with limb loss when comparable benefits would be available to nondisabled individuals.
Proposed law requires carriers to report to the commissioner of insurance by Jan.
Proposed law allows for copayments, deductibles, and coinsurance that are no more restrictive than those applied to other benefits.
1, 2029, on claims experience for plan years 2027–2028.
Proposed law also mandates coverage for repair and replacement when medically necessary, which includes instances where the enrollee'sphysiologicalconditionchanges,thedeviceisirreparablydamaged,orwhenrepair is not cost-effective.
Requires the commissioner to aggregate and report this information to the House and Senate committees on insurance by July 1, 2029.
Proposedlawguaranteesaccesstomedicallynecessaryprosthesesandcustomorthosesfrom a minimum of two distinct in-state providers.
Proposed law provides that the provisions of proposed law do not apply to limited benefit health insurance policies or contracts.
Proposed law stipulates that referral and full reimbursement (with the exception of in-network cost-sharing) is required when medically necessary devices are unavailable within the network.
Proposed law requires the Louisiana Medicaid program to provide coverage for prosthetic and custom orthotic devices and services when medically necessary, in accordance with Medicaid standards and clinical criteria.
Proposed law requires that prosthetic devices are supplied byan accredited facilityand that prosthetic services are prescribed by a licensed physician.
ProposedlawrequiresthesecretaryoftheLa.Dept.ofHealthto submit necessarystateplan amendments,promulgateimplementingrules,andtakeotheractionsneededto carryoutthe law.
Proposed law stipulates that individual healthplansmust recognizeprosthesesandcustom orthosesas rehabilitative and habilitative services for the purpose of essential health benefits.
Proposed law authorizes an annual benefit limit of no less than $50,000 per limb, allowing for more favorable coverage if applicable.
Furthermore, it mandates that health coverage plans report claims data for the plan years 2027-2028 to the commissioner, with aggregated reporting due to legislative committees by July 1, 2029.
ProposedlawdirectstheLouisianaMedicaidprogramtoprovidecoverageforprostheticand custom orthotic devices and services when medically necessary.
Proposed law delineates coverage for devices, services, materials, components, instruction, repair, and replacement as specified in R.S.
22:1049.
Proposed law tasks the Department of Health with submitting state plan amendments, promulgating rules, and undertaking necessary actions for implementation.
Coverage requirementsaresetto takeeffectfornew plansbeginningJanuary1,2027,andforexisting plans upon renewal, but no later than January 1, 2028.
The reporting requirements will commence on July 1, 2029.
(Adds R.S.
(Amends R.S.
22:1049.1 and R.S.
22:1049;
40:1259.11;
Adds R.S.
Repeals R.S.
40:1259.11) Page 9 of 9 CODING:
22:1049) Page 9 of 9 CODING: