SB 5629 — Concerning coverage requirements for prosthetic limbs and custom orthotic braces.

ENGROSSEDS-0881.1 SUBSTITUTE SENATE BILL 5629 State of Washington 69th Legislature 2025 Regular Session By Senate Health & Long-Term Care (originally sponsored by Senators Harris, Chapman, Dozier, Frame, Hasegawa, Liias, Slatter, Trudeau, and Valdez)Valdez READRead FIRSTfirst TIMEtime 02/21/25.02/03/25.

Referred to Committee on Health & Long- Term Care.

reenacting and amending RCW 41.05.017;

(1) NongrandfatheredA group health plans,plan other than small group health plans and health plans offered to public employees and dependents under chapter 41.05 RCW, issued or renewed on or after January 1, 2026, must include coverage for one or more prostheses per limb and custom orthotic braces per limb when medically necessary for the enrollee to participate in any of the following:

p.(b) Instruction to the enrollee on using the devices;

1 ESSB 5629 (b) Instruction to the enrollee on using the devices;

(3)(a)p. Coverage under this section includes coverage for the replacement or repair of a prosthetic limb or custom orthotic brace or for the replacement or repair of any part of such devices, without regard to continuous use or useful lifetime restrictions, if medically necessary because:

1 SB 5629 (3)(a) Coverage under this section includes coverage for the replacement or repair of a prosthetic limb or custom orthotic brace or for the replacement or repair of any part of such devices, without regard to continuous use or useful lifetime restrictions, if medically necessary because:

(4) A health plan subject to this section may not deny coverage for a prosthetic limb or custom orthotic brace for an enrollee with a disability if health care services would otherwise be covered for a nondisabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.

(5) For coverage under this section, a health plan subject to this section may apply normal utilization management and prior authorization practices.

(6) A health plan subject to this section shall provide payment for coverage under this section that is at least equal to the payment and coverage for prosthetic limbs and custom orthotic braces provided under federal laws and regulations for the aged and disabled pursuant to 42 U.S.C.

The commissioner shall aggregate this data by p.plan year in a report and submit the report to the relevant committees of the legislature by December 1, 2028.

2 ESSB 5629 plan year in a report and submit the report to the relevant committees of the legislature by December 1, 2028.

(a) "Prosthetic limb" or "prosthesis" means an external medical device that is used to replace or restore a missing limb or portion ofp. a limb and is deemed medically necessary for an individual with a mobility impairing health condition or disability.

2 SB 5629 of a limb and is deemed medically necessary for an individual with a mobility impairing health condition or disability.

Sec.

2.

RCW 41.05.017 and 2024 c 251 s 5 and 2024 c 242 s 10 are each reenacted and amended to read as follows:

Each health plan that provides medical insurance offered under this chapter, including plans created by insuring entities, plans not subject to the provisions of Title 48 RCW, and plans created under RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 48.200.300 through 48.200.320, 48.43.440, section 1 of this act, and chapter 48.49 RCW.

3 ESSBSB 5629