Prosthetic limb coverage

AN ACT Relating to coverage requirements for prosthetic limbs and 1
custom orthotic braces; reenacting and amending RCW 41.05.017; and 2
adding a new section to chapter 48.43 RCW. 3
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:4
NEW SECTION. Sec. 1. A new section is added to chapter 48.43 5
RCW to read as follows: 6
(1) A health plan issued or renewed on or after January 1, 2026, 7
must include coverage for one or more prostheses per limb and custom 8
orthotic braces per limb when medically necessary for the enrollee to 9
participate in any of the following: 10
(a) Completing activities of daily living or essential job-11
related activities; and 12
(b) Performing physical activities, including but not limited to 13
running, biking, swimming, and strength training, for maximizing the 14
enrollee's lower limb function, upper limb function, or both.15
(2) The coverage required under this section must also include 16
coverage for: 17
(a) Materials, components, and related services necessary to use 18
the devices for their intended purposes; 19
(b) Instruction to the enrollee on using the devices; and20
(c) Reasonable repair or replacement of the devices.21
S-0881.1
SENATE BILL 5629
State of Washington 69th Legislature 2025 Regular Session
By Senators Harris, Chapman, Dozier, Frame, Hasegawa, Liias, Slatter,
Trudeau, and Valdez
Read first time 02/03/25. Referred to Committee on Health & Long-
Term Care.
p. 1 SB 5629
(3)(a) Coverage under this section includes coverage for the 1
replacement or repair of a prosthetic limb or custom orthotic brace 2
or for the replacement or repair of any part of such devices, without 3
regard to continuous use or useful lifetime restrictions, if 4
medically necessary because: 5
(i) Of a change in the physiological condition of the patient;6
(ii) Of an irreparable change in the condition of the device or a 7
part of the device; or 8
(iii) The device, or any part of the device, requires repairs and 9
the cost of such repairs would be more than 60 percent of the cost of 10
a replacement device or of the part being replaced.11
(b) Confirmation from the prescribing health care provider may be 12
required if the prosthetic limb or custom orthotic brace or part 13
being replaced is less than three years old. 14
(4) A health plan may not deny coverage for a prosthetic limb or 15
custom orthotic brace for an enrollee with a disability if health 16
care services would otherwise be covered for a nondisabled person 17
seeking medical or surgical intervention to restore or maintain the 18
ability to perform the same physical activity. 19
(5) For coverage under this section, a health plan may apply 20
normal utilization management and prior authorization practices. Any 21
denial of coverage must be issued in writing with an explanation for 22
determining coverage was not medically necessary. 23
(6) A health plan shall provide payment for coverage under this 24
section that is at least equal to the payment and coverage for 25
prosthetic limbs and custom orthotic braces provided under federal 26
laws and regulations for the aged and disabled pursuant to 42 U.S.C. 27
Sec. 1395k, 1395l, and 1395m and 42 C.F.R. Sec. 414.202, 414.210, 28
414.228, and 410.100. 29
(7) No later than July 1, 2028, each carrier that issues a health 30
plan subject to this section shall report to the office of the 31
insurance commissioner, in a form and manner determined by the 32
commissioner, the number of claims and the total amount of claims 33
paid in the state for the services required by this section for plan 34
years 2026 and 2027. The commissioner shall aggregate this data by 35
plan year in a report and submit the report to the relevant 36
committees of the legislature by December 1, 2028.37
(8) For the purposes of this section: 38
(a) "Prosthetic limb" or "prosthesis" means an external medical 39
device that is used to replace or restore a missing limb or portion 40
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of a limb and is deemed medically necessary for an individual with a 1
mobility impairing health condition or disability. 2
(b) "Custom orthotic brace" means an external medical device that 3
is custom-fabricated or custom-fitted to support, correct, or 4
alleviate neuromuscular or musculoskeletal dysfunction, disease, 5
injury, or deformity, is needed to improve the safety and efficiency 6
of functional mobility, is patient-specific based on the patient's 7
unique physical condition, and is deemed medically necessary for 8
individuals with a mobility impairing health condition or disability.9
Sec. 2. RCW 41.05.017 and 2024 c 251 s 5 and 2024 c 242 s 10 are 10
each reenacted and amended to read as follows: 11
Each health plan that provides medical insurance offered under 12
this chapter, including plans created by insuring entities, plans not 13
subject to the provisions of Title 48 RCW, and plans created under 14
RCW 41.05.140, are subject to the provisions of RCW 48.43.500, 15
70.02.045, 48.43.505 through 48.43.535, 48.43.537, 48.43.545, 16
48.43.550, 70.02.110, 70.02.900, 48.43.190, 48.43.083, 48.43.0128, 17
48.43.780, 48.43.435, 48.43.815, 48.200.020 through 48.200.280, 18
48.200.300 through 48.200.320, 48.43.440, section 1 of this act, and 19
chapter 48.49 RCW. 20
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