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PRINTER'S NO. 1586
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 1391
Session of
2025
INTRODUCED BY GAYDOS, HANBIDGE, GALLAGHER AND BOROWSKI,
MAY 5, 2025
REFERRED TO COMMITTEE ON INSURANCE, MAY 5, 2025
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," in casualty insurance, providing
for reimbursement for custom-fabricated devices, custom-
fitted devices, orthosis, orthotics, over-the-counter
prostheses, orthoses and pedorthic devices, prefabricated
orthoses, prostheses, prosthetics and components of such
devices.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921, is amended by adding a
section to read:
Section 635.11. Reimbursement for Custom-Fabricated Devices,
Custom-Fitted Devices, Orthosis, Orthotics, Over-the-Counter
Prostheses, Orthoses and Pedorthic Devices, Prefabricated
Orthoses, Prostheses, Prosthetics and Components of Such
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Devices.--(a) Except to the extent coverage is provided under
another policy, an individual or group health, sickness and
accident insurance policy, group health insurance plan or policy
or any other form of a managed or capitated care plan, policy,
subscriber contract or certificate, issued by an insurer subject
to 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or
63 (relating to professional health services plan corporations),
the act of December 29, 1972 (P.L.1701, No.364), known as the
"Health Maintenance Organization Act," or this act, which
provides hospital or medical and surgical coverage, shall
provide coverage for custom-fabricated devices, custom-fitted
devices, orthosis, orthotics, over-the-counter prostheses,
orthoses and pedorthic devices, prefabricated orthoses,
prostheses, prosthetics and components of such devices, when
prescribed by a physician, podiatrist, certified registered
nurse practitioner or physician assistant legally authorized to
issue the prescription. Prior to the initial prosthetic,
orthotic, pedorthic or orthotic fitting authorized under this
section, a prosthetist, orthotist, pedorthist or orthotics
fitter shall have the following duties:
(1) Ensure that the patient has obtained a prescription,
accompanied by clinical notes for treatment, from a physician,
podiatrist, certified registered nurse practitioner or physician
assistant. The prescription may impose conditions and
restrictions on the course of treatment as required by sound
medical practice.
(2) Verify that the patient has undergone a medical
diagnostic examination or that the results of a recently
performed medical diagnostic examination have been reviewed by a
physician, podiatrist, certified registered nurse practitioner,
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or physician assistant.
(3) Retain in the patient's file a copy of the prescription
and the results of the medical diagnostic examination.
(b) The benefits specified under this section may be
provided through a combination of policies, contracts,
certificates or riders, including major medical contracts, and
shall be recognized within this Commonwealth.
(c) The following shall apply:
(1) An insurer may require preauthorization to determine the
medical necessity and eligibility of benefits for custom-
fabricated devices, custom-fitted devices, orthosis, orthotics,
over-the-counter prostheses, orthoses and pedorthic devices,
prefabricated orthoses, prostheses, prosthetics and components
of such devices.
(2) Coverage under this section shall extend to the fitting,
repair or replacement of custom-fabricated devices, custom-
fitted devices, orthosis, orthotics, over-the-counter
prostheses, orthoses and pedorthic devices, prefabricated
orthoses, prostheses, prosthetics and components of such
devices, when the fitting, repair or replacement is deemed
medically necessary. Coverage under this section shall not be
provided for the fitting, repair or replacement necessitated by
negligence in proper care and maintenance or by an abusive act
committed by the individual utilizing such devices or
components.
(3) An insurer shall require that custom-fabricated devices,
custom-fitted devices, orthosis, orthotics, over-the-counter
prostheses, orthoses and pedorthic devices, prefabricated
orthoses, prostheses, prosthetics and components of such devices
be rendered by an orthotic fitter, orthotist, pedorthist,
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podiatrist or prosthetist licensed in this Commonwealth and
contracted with the insurer, and that such devices and
components be provided by an orthotic fitter, orthotist,
pedorthist, podiatrist or prosthetist licensed in this
Commonwealth and contracted with the insurer.
(4) Coverage under this section shall be required for a
prosthetic, orthotic, pedorthic or orthotic fitting device
designed exclusively for recreational, organized or adaptive
sports purposes.
(5) Coverage under this section shall remain subject to any
copayment, coinsurance or deductible amounts imposed by an
insurer subject to this section for similar coverages under the
same policy or contract.
(d) On and after the effective date of this section,
Medicaid and a contracted insurer shall reimburse for custom-
fabricated devices, custom-fitted devices, orthosis, orthotics,
over-the-counter prostheses, orthoses and pedorthic devices,
prefabricated orthoses, prostheses, prosthetics and components
of such devices at the rate of reimbursement established for
such devices and components under the Federal Medicare
reimbursement schedule.
(e) A physician, podiatrist, certified registered nurse
practitioner or physician assistant that prescribes custom-
fabricated devices, custom-fitted devices, orthosis, orthotics,
over-the-counter prostheses, orthoses and pedorthic devices,
prefabricated orthoses, prostheses, prosthetics and components
of such devices shall document the medical necessity of the
prescription as the proposed course of treatment.
(f) As used in this section, the following words and phrases
shall have the meanings given to them in this subsection unless
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the context clearly indicates otherwise:
"Custom-fabricated device" means a prosthesis, orthosis or
pedorthic device fabricated to comprehensive measurements or a
mold for use by a patient in accordance with a prescription,
which requires substantial clinical and technical judgment in
its design, fabrication and fitting.
"Custom-fitted device" means a prefabricated prosthesis,
orthosis or pedorthic device sized or modified for use by a
patient in accordance with a prescription, which requires
substantial clinical judgment and substantive alteration in its
design for appropriate use.
"Orthosis" means a custom-fabricated or custom-fitted device
designed to externally provide support, alignment or prevention
to the body or a limb for the purpose of correcting or
alleviating a neuromuscular or musculoskeletal disease, injury
or deformity.
"Orthotic fitter" means an individual licensed in this
Commonwealth to properly fit, dispense and adjust prefabricated
orthotic devices as authorized by a prescription from a
physician, podiatrist, certified registered nurse practitioner
or physician assistant.
"Orthotics" means the practice of evaluating, measuring,
designing, fabricating, assembling, fitting, adjusting or
servicing an orthosis for the correction or alleviation of
neuromuscular or musculoskeletal dysfunction, disease, injury or
deformity.
"Orthotist" means an individual, other than a physical
therapist, occupational therapist or orthotic fitter, licensed
in this Commonwealth to practice orthotics as authorized by a
prescription from a physician, podiatrist, certified registered
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nurse practitioner or physician assistant.
"Over-the-counter prostheses, orthoses and pedorthic devices"
means prefabricated, mass-produced items that are prepackaged
and require no professional advice or judgment in size selection
or use, including fabric or elastic supports, corsets, generic
arch supports and elastic hose.
"Pedorthic device" means therapeutic shoes, shoe
modifications made for therapeutic purposes, partial foot
prostheses, foot orthoses and below-the-knee pedorthic
modalities. The term does not include nontherapeutic,
accommodative inlays, nontherapeutic accommodative footwear,
unmodified, nontherapeutic over-the-counter shoes or
prefabricated unmodified or unmodifiable foot care and footwear
products.
"Pedorthics" means the practice of evaluating, measuring,
designing, fabricating, assembling, fitting, adjusting or
servicing necessary to accomplish the application of a pedorthic
device for the prevention or amelioration of painful or
disabling conditions related to the lower extremities.
"Pedorthist" means an individual licensed in this
Commonwealth to practice pedorthics as authorized by
prescription from a physician, podiatrist certified as a
registered nurse practitioner or physician assistant.
"Podiatrist" means an individual licensed under the act of
March 2, 1956 (1955 P.L.1206, No.375), known as the "Podiatry
Practice Act," to practice podiatry.
"Prefabricated orthosis" means a brace or support designed to
provide for alignment, correction or prevention of neuromuscular
or musculoskeletal dysfunction, disease, injury or deformity.
The term does not include fabric or elastic supports, corsets,
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arch supports, low-temperature plastic splints, trusses, elastic
hose, canes, crutches, soft cervical collars, dental appliances
or other similar devices carried in stock and sold as over-the-
counter items by a drug store, department store, corset shop or
surgical supply facility.
"Prosthesis" means a custom-designed, custom-fabricated,
custom-fitted or custom-modified device to replace an absent
external limb for purposes of restoring physiological function,
which is not surgically implanted. The term does not include
artificial eyes, ears, fingers, toes, dental appliances,
cosmetic devices, such as artificial breasts, eyelashes or wigs,
or other devices that do not significantly impact the
musculoskeletal functions of the body.
"Prosthetics" means the practice of evaluating, measuring,
designing, fabricating, assembling, fitting, adjusting or
servicing a prosthesis.
"Prosthetist" means an individual, other than a physical
therapist or occupational therapist, licensed in this
Commonwealth to practice prosthetics as authorized under
prescription from a physician, podiatrist, certified registered
nurse practitioner or physician assistant.
Section 2. This act shall apply as follows:
(1) For health insurance policies for which either rates
or forms are required to be filed with the Federal Government
or the Insurance Department, this act shall apply to any
policy for which a form or rate is first filed on or after
180 days after the effective date of this paragraph.
(2) For health insurance policies for which neither
rates nor forms are required to be filed with the Federal
Government or the Insurance Department, this act shall apply
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to any policy issued or renewed on or after 180 days after
the effective date of this paragraph.
Section 3. If a State plan amendment or Federal waiver
necessary for the provisions of this act is approved or is not
necessary, the Secretary of Human Services shall transmit a
notice to the Legislative Reference Bureau for publication in
the next available issue of the Pennsylvania Bulletin.
Section 4. This act shall take effect in 60 days.
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