Require health insurance coverage of orthotic, prosthetic devices

As Introduced

136th
General Assembly

Regular
Session
H. B. No. 564

2025-2026

Representatives Jarrells, Schmidt

Cosponsors: Representatives
Piccolantonio, Rogers, Brennan, Troy, Lett, Rader, Sigrist, Sims,
Baker, Grim, Thomas, C., Upchurch, Lawson-Rowe, White, E., Holmes,
LaRe

To
enact sections 3902.65, 3902.651, 3902.652, 3902.653
,
and 3902.654

of the Revised Code
to
require health insurance coverage of orthotic and prosthetic devices.

BE
IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section
1.
That
sections 3902.65, 3902.651, 3902.652, 3902.653
,
and 3902.654

of the Revised Code be enacted to read as follows:

Sec.
3902.65.
(A)
For the purposes of sections 3902.65 to 3902.654 of the Revised Code,
"qualifying health benefit plan" means a health benefit
plan issued, amended, or renewed in this state on or after the
effective date of this section, and that provides coverage for
hospital, medical, or surgical expenses. A health benefit planned is
"renewed" for the purposes of this division not later than
the first anniversary of the original contract date that occurs on or
after the effective date of this section.

(B)
Notwithstanding section 3901.71 of the Revised Code, a qualifying
health benefit plan shall provide coverage for prosthetic and
orthotic devices that, at a minimum, equals the coverage and payment
for prosthetic and orthotic devices provided under federal laws and
regulations for the aged and disabled pursuant to 42 U.S.C. 1395k,
1395l, and 1395m, and 42 C.F.R. 410.100, 414.202, 414.210, and
414.228. The coverage shall include both of the following:

(1)
Coverage for the purchase, fitting, adjustment, repair, and
replacement of one or more prosthetic or orthotic devices as needed
to accomplish both of the following, as applicable:

(a)
The replacement of all or part of a missing body part and its
adjoining tissues;

(b)
The replacement of, when possible, all of the function of a
permanently useless or malfunctioning body part as necessary to do
all of the following:

(i)
Complete activities of daily living or essential job-related
activities;

(ii)
Perform physical activities such as running, biking, swimming, or
strength training, and to maximize the covered person's whole-body
health and lower and upper limb function;

(iii)
Showering or bathing.

(2)
Coverage for both of the following with respect to the devices
described in division (B)(1) of this section:

(a)
All materials and components necessary to use the devices;

(b)
Instruction to a covered person on using the devices.

(C)
A health plan issuer may impose utilization review procedures with
regard to coverage provided under division (B) of this section,
provided that such review is not applied in a discriminatory manner
solely on the basis of a covered person's actual or perceived
disability.

(D)
For purposes of any state or federal requirement for coverage of
essential health benefits, coverage of a prosthetic or orthotic
device shall be considered a habilitative or rehabilitative benefit.

(E)
With respect to a covered person, coverage of one or more prosthetic
or orthotic devices is medically necessary if it is determined by a
covered person's provider to be the most appropriate model that
adequately meets the medical needs of the covered person, including
any orthotic or prosthetic devices that enable the covered person to
do any or all of the following:

(1)
Completing activities of daily living or essential job-related
activities;

(2)
Performing physical activities, such as running, biking, swimming, or
strength training;

(3)
Maximizing the covered person's whole-body health;

(4)
Maximizing the covered person's lower or upper limb function;

(5)
Showering or bathing.

(F)
A health plan issuer shall render utilization review determinations
in a nondiscriminatory manner and shall not deny coverage for
habilitative or rehabilitative benefits, including prosthetics or
orthotics, solely on the basis of a covered person's actual or
perceived disability.

(G)
A health plan issuer shall not deny a prosthetic or orthotic benefit
for a covered person with limb loss, absence, or difference that
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.

(H)(1)
A qualifying health benefit plan shall include language describing a
covered person's rights under this section in its evidence of
coverage and any benefit denial letters.

(2)
With regard to prosthetic and orthotic device coverage, any denials
of coverage or prior authorization or pre-determination decisions
shall be issued in writing.

(I)
Nothing in this section shall be construed as prohibiting a health
plan issuer from imposing cost-sharing with regard to coverage of
prosthetic or orthotic devices, provided that any cost-sharing
requirements are not more restrictive than the cost-sharing
requirements applicable to the plan's coverage for inpatient
physician and surgical services. Prosthetic and orthotic device
coverage shall not be made subject to separate cost-sharing
requirements that are applicable only with respect to that coverage.

(J)(1)
A qualifying health benefit plan shall ensure access to medically
necessary clinical care and to prosthetic and orthotic devices and
technology from not less than two distinct prosthetic and orthotic
providers located in this state in the plan's provider network.

(2)
In the event that medically necessary covered orthotics and
prosthetics are not available from an in-network provider, a health
plan issuer shall provide processes to refer a covered person to an
out-of-network provider and shall fully reimburse the out-of-network
provider at a mutually agreed upon rate, less any applicable
cost-sharing, determined on an in-network basis.

(K)(1)
A qualifying health benefit plan shall provide coverage for the
replacement of a prosthetic or orthotic device covered pursuant to
this section, or for the replacement of any part of such a device, as
applicable, without regard to continuous use or useful lifetime
restrictions, if an ordering health care provider determines that the
provision of a replacement device, or a replacement part of such a
device, is necessary due to any of the following:

(a)
A change in the physiological condition of the covered person;

(b)
An irreparable change in the condition of the device or in a part of
the device;

(c)
The condition of the device, or a part of the device, requires
repairs and the cost of such repairs is more than sixty per cent of
the cost of a replacement device or of the part being replaced.

(2)
A health plan issuer may require, before covering a replacement
prosthetic or orthotic device or part of such a device that is less
than three years old, that a prescribing health care provider confirm
the replacement.

Sec.
3902.651.
Both
of the following are unfair and deceptive practices in the business
of insurance under sections 3901.19 to 3901.26 of the Revised Code:

(A)
Canceling or changing premiums, benefits, or conditions under a
qualifying health benefit plan on the basis of a covered person's
actual or perceived disability;

(B)
Denying a prosthetic or orthotic benefit under a qualifying health
benefit plan for a covered person with limb loss, absence, or
difference that 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.

Sec.
3902.652.
Not
later than the first day of March of the second year that begins
after the effective date of this section, and annually thereafter,
each health plan issuer that issues a qualifying health benefit plan
shall report to the superintendent of insurance on the health plan
issuer's experience providing coverage pursuant to section 3902.65 of
the Revised Code for the previous plan year. The report shall be in a
form prescribed by the superintendent and shall include the number of
claims made and the total amount of claims paid in this state for the
services required by section 3902.65 of the Revised Code. The
superintendent shall aggregate this data by plan year in the report
and submit the report to the standing committees of the senate and
the house of representatives having jurisdiction over health coverage
and insurance matters.

Sec.
3902.653.
(A)
Not later than one year after the effective date of this section, and
annually thereafter for five years, each health plan issuer that
issues a health benefit plan in this state shall report to the
superintendent of insurance on the health plan issuer's experience
related to coverage provided under section 3902.65 of the Revised
Code.

(B)
The report shall be in a form prescribed by the superintendent and
shall include, at minimum, the total number of claims made, as well
as the total amount paid, in this state for the coverage required
under section 3902.65 of the Revised Code.

(C)
The superintendent shall aggregate the data received under this
section by plan year and make a report to the standing committees of
the senate and house of representatives having jurisdiction over
insurance matters.

Sec.
3902.654.
(A)
Not later than one year after the effective date of this section, the
superintendent of insurance shall issue public guidance on what care
and devices are needed to restore full function for a covered person
with limb loss, limb difference, or mobility impairment in relation
to the coverage required under division (B)(1) of section 3902.65 of
the Revised Code.

(B)
The superintendent shall update this guidance as often as the
superintendent deems necessary.

Section
2.
Sections
3902.65, 3902.651, 3902.652, 3902.653, and 3902.654 of the Revised
Code, as enacted by this act, shall take effect on January 1, 2027,
and apply to health benefit plans issued, amended, or renewed on or
after that date.