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HLS 26RS-846 ORIGINAL
2026 Regular Session
HOUSE BILL NO. 477
BY REPRESENTATIVE HEBERT
INSURANCE/HEALTH: Modifies provisions of law regarding health insurance coverage
of prosthetic and custom orthotic devices and services
1 AN ACT
2 To enact R.S. 22:1049.1 and Part IX of Chapter 5-E of Title 40 of the Louisiana Revised
3 Statutes of 1950, to be comprised of R.S. 40:1259.11, and to repeal R.S. 22:1049,
4 relative to health insurance; to require coverage for prosthetic and custom orthotic
5 devices and associated services; to establish criteria for medical necessity
6 determinations; to delineate coverage standards, encompassing multiple devices,
7 materials, components, repair, and replacement; to provide requirements for prior
8 authorization and cost-sharing; to provide nondiscrimination provisions; to provide
9 for network adequacy standards; to set reporting requirements; to provide for
10 definitions; and to provide for related matters.
11 Be it enacted by the Legislature of Louisiana:
12 Section 1. R.S. 22:1049.1 is hereby enacted to read as follows:
13 §1049.1. Coverage for prosthetic and custom orthotic devices and services
14 A. As used in this Section:
15 (1) "Accredited facility" means any entity that is accredited by the American
16 Board for Certification in Orthotics, Prosthetics, and Pedorthics (ABCop) or by the
17 Board for Orthotist/Prosthetist Certification (BOC) and that provides prosthetic
18 devices or prosthetic services.
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HB NO. 477
1 (2) "Advanced practice provider" means a healthcare professional who is
2 licensed in this state and authorized under state law to evaluate patients and to
3 prescribe orthotic and prosthetic devices within the provider's scope of practice.
4 (3) "Health coverage plan" means any hospital, health, or medical expense
5 insurance policy, hospital or medical service contract, employee welfare benefit plan,
6 contract or agreement with a health maintenance organization or a preferred provider
7 organization, health and accident insurance policy, or any other insurance contract
8 of this type, including a group insurance plan and the Office of Group Benefits
9 programs.
10 (4) "Prosthetic device" or "prosthesis" means an artificial limb designed to
11 maximize function, stability, and safety of the patient. The term does not include
12 artificial eyes, ears, noses, dental appliances, ostomy products, or devices such as
13 eyelashes or wigs.
14 (5) "Prosthetic services" means the science and practice of evaluating,
15 measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or
16 servicing of a prosthesis through the replacement of external parts of a human body
17 lost due to amputation or congenital deformities to restore function, cosmesis, or
18 both. It also includes any medically necessary clinical care.
19 (6) "Orthosis" means a custom-designed, custom-fabricated, custom-fitted,
20 pre-fabricated, or modified device to treat a neuromusculoskeletal disorder or
21 acquired condition.
22 (7) "Orthotic services" means the science and practice of evaluating,
23 measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or
24 servicing a custom orthosis. Prosthetists, orthotic assistants, and orthotic fitters who
25 are credentialed by a nationally recognized Orthotic, Prosthetic and Pedorthic
26 certifying board or are licensed, if applicable, may be privileged based on written
27 objective criteria to provide orthotic care. Certified or licensed pedorthists may be
28 privileged based on written objective criteria to provide lower extremity orthotic
29 care.
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HLS 26RS-846 ORIGINAL
HB NO. 477
1 B. Any health coverage plan specified in Subsection P of this Section that
2 is delivered, issued for delivery, renewed, or otherwise contracted for in this state on
3 or after January 1, 2027, shall provide coverage for prosthetic and custom orthotic
4 devices and services. At a minimum, such coverage shall equal the coverage and
5 prevailing payment rates for prosthetic and orthotic devices provided under federal
6 laws and regulations for older adults and persons with disabilities pursuant to 42
7 U.S.C. 1395k, 1395l, and 1395m and 42 CFR 414.202, 414.210, 414.228, and
8 410.100. Covered benefits shall be provided for more than one prosthesis or orthosis
9 when medically necessary as further provided in this Section.
10 C. Eligibility for prosthetic and custom orthotic devices and services is based
11 on medical necessity as determined by the enrollee's physician or other advanced
12 practice provider. Medical necessity includes the most appropriate prosthesis or
13 custom orthosis that adequately meets the medical needs of the enrollee to restore or
14 maintain the ability to perform activities of daily living and essential job-related
15 functions.
16 D. In addition to the device required pursuant to Subsection B of this
17 Section, a prosthetic or custom orthotic device determined by the enrollee's
18 prosthetic or orthotic care provider to be the most appropriate device to meet the
19 enrollee's medical needs for purposes of performing physical activities including but
20 not limited to running, biking, swimming, and strength training, shall be covered
21 when the treating physician or other advanced practice provider determines that such
22 device is necessary to enable the enrollee to engage in physical activity and to
23 maximize whole-body health and lower or upper limb function.
24 E. In addition to the devices required pursuant to Subsections B and C of this
25 Section, a prosthetic or custom orthotic device determined by the enrollee's
26 prosthetic or orthotic care provider to be the most appropriate device to meet the
27 enrollee's medical needs for purposes of showering or bathing shall be covered when
28 the treating physician or other advanced practice provider determines that such
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HB NO. 477
1 device is necessary to enable the enrollee to safely engage in bathing and showering
2 and to maintain whole-body health and lower or upper-limb function.
3 F. Coverage required by this Section includes all materials and components
4 necessary for the use of prosthetic and custom orthotic devices.
5 G. Coverage required by this Section includes instruction to the enrollee on
6 the proper use of the prosthetic or custom orthotic device.
7 H. Coverage required by this Section includes medically necessary repair or
8 replacement of a prosthetic or custom orthotic device. Payment shall be made for
9 the replacement of a device or any part thereof, without regard to continuous use or
10 useful lifetime restrictions, when an ordering healthcare provider determines that
11 replacement is necessary due to any of the following:
12 (1) A change in the physiological condition of the enrollee.
13 (2) An irreparable change in the condition of the device or a part of the
14 device.
15 (3) The condition of the device or part requires repairs, and the cost of such
16 repairs would exceed sixty percent of the cost of a replacement device or part.
17 I. A health coverage plan may require confirmation from the prescribing
18 healthcare provider if the prosthetic or custom orthotic device or part being replaced
19 is less than three years old.
20 J. A health coverage plan that covers prosthetic and custom orthotic devices
21 shall include in its evidence of coverage a description of the insured's rights under
22 this Section. Any denial of coverage based on medical necessity shall be in writing
23 and shall include clear reasoning and an explanation of how the request does not
24 meet medical necessity standards. Any denial or limit of coverage based on a lack
25 of medical necessity may be appealed in accordance with R.S. 22:3070 et seq.
26 Medical necessity determinations shall consider information and recommendations
27 from the treating physician in consultation with the enrollee, including information
28 in the medical record of the treating orthotist or prosthetist and the results of a
29 functional assessment. Such assessment shall consider but not be limited to all of the
30 following:
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HB NO. 477
1 (1) The insured's past history, including prior use of prosthetic or orthotic
2 devices if applicable.
3 (2) The insured's current condition, including the status of the residual limb.
4 (3) The insured's desire to ambulate with respect to lower limb prosthetic
5 devices, maximize upper limb function with respect to upper limb prosthetic devices,
6 and the insured's desire and ability to use an orthosis to maintain functional abilities.
7 K. An individual health plan delivered, issued for delivery, or renewed in
8 this state that covers prosthetic and custom orthotic devices shall consider these
9 benefits rehabilitative and habilitative services and devices for purposes of any state
10 or federal requirement for coverage of essential health benefits.
11 L. A health coverage plan may require prior authorization for prosthetic and
12 custom orthotic devices and services in the same manner as other covered benefits,
13 if such procedures are applied in a nondiscriminatory manner. Utilization review
14 procedures shall not deny coverage for habilitative or rehabilitative benefits,
15 including prosthetics or custom orthotics, solely on the basis of an insured's actual
16 or perceived disability.
17 M. A health coverage plan may impose co-payments, deductibles, or
18 coinsurance amounts on prosthetic and custom orthotic devices and services. Such
19 cost-sharing shall not be greater than that applied to other benefits under the plan.
20 Repair and replacement of prosthetic and custom orthotic devices shall be covered
21 subject to cost-sharing that is no more restrictive than that applied to other benefits,
22 unless necessitated by theft or loss.
23 N. A health coverage plan shall require that prosthetic and custom orthotic
24 devices be provided by an accredited facility. The prescription for such prosthetic
25 and custom orthotic services shall be issued by a licensed physician, and the
26 provision of these services shall occur at an accredited facility.
27 O. Coverage required in accordance with this Section shall be aligned with,
28 and not more restrictive than, the provisions applicable to other benefits within the
29 health coverage plan. An insurer shall not deny a prosthetic or custom orthotic
30 benefit to an individual with limb loss, limb absence, or limb impairment if such
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1 benefits would otherwise be available to a non-disabled individual seeking medical
2 or surgical intervention to restore or maintain the ability to perform the same
3 physical activity.
4 P. A health coverage plan that provides coverage for prosthetic and custom
5 orthotic services shall ensure access to medically necessary clinical care for
6 prosthetic and custom orthotic devices and technology. There shall be a minimum
7 of two distinct prosthetic and custom orthotic service providers within this state who
8 are also part of the plan's authorized provider network. If medically necessary
9 covered orthotic or prosthetic devices or services are not available from an in-
10 network provider, the insurer shall establish and maintain a process to refer the
11 enrollee to an out-of-network provider. The insurer shall reimburse that provider at
12 a mutually agreed-upon rate, reduced only by the member's cost-sharing that would
13 apply if the service were obtained from an in-network provider.
14 Q. Each carrier that issues a health plan subject to this Section shall report
15 to the commissioner of insurance on its experience pursuant to this Section for plan
16 years 2027-2028. The report shall be in a form prescribed by the commissioner of
17 insurance and shall include the number of claims and the total amount of claims paid
18 in this state for the services required by this Section. The commissioner of insurance
19 shall aggregate this data by plan year in a report and submit the report to the House
20 and Senate committees on insurance.
21 R. The provisions of this Section do not apply to limited benefit health
22 insurance policies or contracts.
23 Section 2. Part IX of Chapter 5-E of Title 40 of the Louisiana Revised Statutes of
24 1950, comprised of R.S. 40:1259.11, is hereby enacted to read as follows:
25 PART IX. PROSTHETIC AND CUSTOM ORTHOTIC
26 DEVICES AND SERVICES COVERAGE
27 §1259.11. Prosthetic and custom orthotic devices and services; Medicaid coverage
28 A. The Louisiana Medicaid program shall provide coverage for prosthetic
29 and custom orthotic devices and services to an enrollee when such devices or
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1 services are deemed medically necessary in accordance with the standards and
2 clinical criteria set forth by the Medicaid program.
3 B. Coverage includes the devices, services, materials, components,
4 instruction, repair, and replacement as delineated in R.S. 22:1049.1, including but
5 not limited to services required to restore or maintain the ability to perform activities
6 of daily living, essential job-related functions, and medically necessary physical
7 activity. The definitions provided in R.S. 22:1049.1 apply to this Section unless the
8 context clearly requires otherwise.
9 C. Pursuant to this Section, the secretary of the Louisiana Department of
10 Health shall do all of the following:
11 (1) Submit to the Centers for Medicare and Medicaid Services all necessary
12 state plan amendments.
13 (2) Promulgate all necessary rules and regulation in accordance with the
14 Administrative Procedure Act.
15 (3) Take any other actions necessary to implement the provisions of this
16 Chapter.
17 Section 3. R.S. 22:1049 is hereby repealed in its entirety.
18 Section 4. The coverage requirements provided by the provisions of R.S. 22:1049.1
19 as enacted by Section 1 of this Act shall apply to any health coverage plan delivered, issued
20 for delivery, renewed, or otherwise contracted for in this state beginning January 1, 2027.
21 Section 5. The report required to be compiled and submitted to the commissioner
22 of insurance as required by the provisions of R.S. 22:1409.1(Q) as enacted by Section 1 of
23 this Act shall be due beginning July 1, 2029.
24 Section 6. This Act shall become effective upon signature by the governor or, if not
25 signed by the governor, upon expiration of the time for bills to become law without signature
26 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
27 vetoed by the governor, and subsequently approved by the legislature, this Act shall become
28 effective on the day following such approval.
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HLS 26RS-846 ORIGINAL
HB NO. 477
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 477 Original 2026 Regular Session Hebert
Abstract: Mandates that health coverage plans provide comprehensive coverage for
prosthetic and custom orthotic devices and associated services. This includes
coverage for multiple devices, materials and components, instructional support,
repairs and replacements when deemed medically necessary. Outlines protocols for
medical necessity determinations, prior authorization processes, cost-sharing
obligations, nondiscrimination provisions, network adequacy standards, relevant
definitions, and reporting requirements. Excludes limited benefit health insurance
policies or contracts. Establishes Medicaid coverage for prosthetic and custom
orthotic devices and associated services.
Present law requires health coverage plans to provide coverage for prosthetic and orthotic
devices. Defines "accredited facility", "health coverage plan", "prosthetic device", and
"prosthetic services". Present law specifies that devices be deemed medically necessary and
prescribed by a licensed physician. Present law authorizes health coverage plans to apply
standard utilization review procedures and cost-sharing requirements to benefits. Provides
that coverage for prosthetic and orthotic devices be subject to the same terms and conditions
applicable to other medical and surgical benefits under the plan.
Proposed law repeals present 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
be at least equal to Medicare coverage and payment rates for devices and services. Proposed
law ensures that multiple devices are covered when medically necessary.
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 medically necessary.
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.
Requires that benefits be treated as rehabilitative and habilitative services for essential health
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.
Authorizes cost-sharing but prohibits cost-sharing requirements that are more restrictive than
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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Proposed law requires health coverage plans to ensure access to medically necessary clinical
care and to maintain a network that includes at least two prosthetic and orthotic service
providers. Requires referral to and reimbursement of out-of-network providers when
medically necessary services are unavailable in-network.
Proposed law defines “accredited facility”, "advanced practice provider", “health coverage
plan”, “prosthetic device”, “prosthetic services”, “orthosis”, and “orthotic services”.
Proposed law requires carriers to report to the commissioner of insurance by Jan. 1, 2029,
on claims experience for plan years 2027–2028. Requires the commissioner to aggregate
and report this information to the House and Senate committees on insurance by July 1,
2029.
Proposed law provides that the provisions of proposed law do not apply to limited benefit
health insurance policies or contracts.
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 the secretary of the La. Dept. of Health to submit necessary state plan
amendments, promulgate implementing rules, and take other actions needed to carry out the
law.
Effective upon signature of governor or lapse of time for gubernatorial action.
(Adds R.S. 22:1049.1 and R.S. 40:1259.11; Repeals R.S. 22:1049)
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