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AB1121: Bill Text
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2025 - 2026 LEGISLATURE
LRB-6439/1
EKL:ajk&cdc
2025 ASSEMBLY BILL 1121
March 13, 2026 - Introduced by Representatives
Hysell
,
Stubbs
,
Snyder
,
Brown
,
DeSanto
,
Emerson
,
Franklin
,
Joers
,
McCarville
,
Miresse
,
Novak
,
Ortiz-Velez
,
Sinicki
,
Taylor
,
Tenorio
,
Clancy
and
Sheehan
, cosponsored by Senators
Ratcliff
,
Smith
,
Testin
,
Spreitzer
,
L. Johnson
and
Larson
. Referred to Committee on Insurance.
AB1121,1,2
1
An Act
to create
609.865 and 632.895 (16g) of the statutes;
relating to:
health
2
insurance coverage of prosthetic limbs and custom orthotic braces.
Analysis by the Legislative Reference Bureau
This bill requires health insurance policies and self-insured governmental health plans to provide coverage of prosthetic limbs and custom orthotic braces (devices) when medically necessary for an individual to participate in activities of daily living or essential job-related activities or to perform physical activities for maximizing limb function, or to meet the individual’s medical needs for purposes of showering or bathing.
The bill specifies that coverage must include the materials, components, and related services necessary to use a device for its intended purpose; any instruction provided to the individual on using the device; and the reasonable repair of the device. The bill also requires coverage of more significant repairs or replacement of the device, without regard to continuous use or useful lifetime restrictions, when medically necessary due to a change in the individual’s physiological condition or an irreparable change in the device’s condition or if the cost to repair the device exceeds 60 percent of the device’s replacement cost.
The bill requires that the coverage must be, at a minimum, equal to the coverage and payment for prosthetic and orthotic devices provided under the federal Medicare program.
The bill provides that the coverage may only be subject to the cost-sharing provisions that apply generally to the coverage provided under the policy or plan for inpatient physician and surgical services. The bill also requires that a managed care plan must ensure access to medically necessary clinical care and the devices from at least two in-network providers in this state. If the care and services are not available from an in-network provider, the managed care plan must provide a process to refer an individual to an out-of-network provider and must fully reimburse that provider at a mutually agreed upon rate.
This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.
For further information see the state fiscal estimate, which will be printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
AB1121,1
1
Section
1
.
609.865 of the statutes is created to read:
AB1121,2,4
2
609.865 Coverage of prosthetic limbs and custom orthotic braces.
3
Limited service health organizations, preferred provider plans, and defined
4
network plans are subject to s. 632.895 (16g).
AB1121,2
5
Section
2
.
632.895 (16g) of the statutes is created to read:
AB1121,2,7
6
632.895 (16g)
Prosthetic limbs and custom orthotic braces
. (a) In this
7
subsection:
AB1121,2,9
8
1. “Custom orthotic brace” means an external medical device that meets all of
9
the following conditions:
AB1121,2,11
10
a. The device is fabricated or custom fitted to support, correct, or alleviate
11
neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity.
AB1121,2,12
12
b. The device is personalized based on the patient’s unique physical condition.
AB1121,2,14
13
2. “Insured” includes an enrollee under a self-insured health plan of the state
14
or a county, city, village, town, or school district.
AB1121,2,16
15
3. “Prosthesis” means an external medical device that meets all of the
16
following conditions:
AB1121,3,2
1
a. The device is custom designed, fabricated, fitted, or modified, or any
2
combination thereof.
AB1121,3,5
3
b. The device is used to replace or restore a missing limb or portion of a limb,
4
used to restore physiological function or cosmesis due to a missing limb, or used for
5
any combination thereof.
AB1121,3,9
6
(b) Subject to pars. (c) to (i), every disability insurance policy, and every self-
7
insured health plan of the state or a county, city, village, town, or school district,
8
shall provide coverage for one or more prostheses per limb and one or more custom
9
orthotic braces per limb when any of the following conditions are met:
AB1121,3,12
10
1. An insured’s appropriate licensed health care provider determines that the
11
prosthesis or custom orthotic brace is the most appropriate prosthetic or orthotic
12
device that is medically necessary for the insured to do any of the following:
AB1121,3,13
13
a. Participate in activities of daily living or essential job-related activities.
AB1121,3,15
14
b. Perform physical activities, including running, biking, swimming, and
15
strength training, for maximizing lower limb function or upper limb function.
AB1121,3,18
16
2. An insured’s appropriate licensed health care provider determines that the
17
prosthesis or custom orthotic device is the most appropriate prosthetic or orthotic
18
device that meets the insured’s medical needs for purposes of showering or bathing.
AB1121,3,22
19
(c) Coverage under par. (b) shall, at a minimum, equal the coverage and
20
payment for prosthetic and orthotic devices provided under federal programs
21
pursuant to
42 USC 1395k
,
1395l
, and
1395m
and
42 CFR 410.100
,
414.202
,
22
414.210
, and
414.228
.
AB1121,4,3
23
(d) Coverage under par. (b) shall include the materials, components, and
24
related services necessary to use the prosthesis or custom orthotic brace described
1
in par. (b) for its intended purpose; any instruction provided to the insured on using
2
the prosthesis or custom orthotic brace; and the reasonable repair of the prosthesis
3
or orthotic custom brace, or a part thereof.
AB1121,4,7
4
(e) Coverage under par. (b) shall include the replacement or repair, other than
5
a repair covered under par. (d), of a prosthesis or custom orthotic brace described in
6
par. (b), or a part thereof, without regard to continuous use or useful lifetime
7
restrictions, if any of the following conditions are met:
AB1121,4,10
8
1. The repair or replacement is medically necessary due to a change in the
9
physiological condition of the insured or an irreparable change in the condition of
10
the prosthesis or custom orthotic brace, or a part thereof.
AB1121,4,13
11
2. The prosthesis or custom orthotic brace, or a part thereof, requires repair
12
and the repair cost exceeds 60 percent of the replacement cost of the prosthesis,
13
custom orthotic brace, or part.
AB1121,4,17
14
(f) For coverage under par. (e), a policy or plan may require confirmation from
15
an appropriate licensed health care provider that a condition in par. (e) 1. or 2. is
16
satisfied if a prosthesis, custom orthotic brace, or part being replaced is less than 3
17
years old.
AB1121,4,21
18
(g) Coverage required under this subsection may be subject to normal
19
utilization management and prior authorization practices. Any denial of coverage
20
under this paragraph shall be issued in writing and include a detailed explanation
21
of the reason for the denial.
AB1121,5,2
22
(h) Any denial of coverage under this subsection based on medical necessity
23
shall be issued in writing and include a detailed explanation of the reason for the
1
denial, including a description of why the request or claim for coverage does not
2
meet medical necessity standards.
AB1121,5,5
3
(i) Coverage under par. (b) may be subject only to the cost-sharing provisions
4
that apply generally to the coverage provided under the policy or plan for inpatient
5
physician and surgical services.
AB1121,5,12
6
(j) A managed care plan that provides coverage subject to this subsection
7
shall ensure access to medically necessary clinical care, and prostheses and custom
8
orthotic braces and technology, from no less than 2 providers in the plan’s network
9
located in this state. If the care and services are not available from an in-network
10
provider, the plan shall provide a process to refer an insured to an out-of-network
11
provider and shall fully reimburse the out-of-network provider at a mutually agreed
12
upon rate less the cost sharing determined on an in-network basis.
AB1121,3
13
Section
3
. Initial applicability.
AB1121,5,16
14
(
1
)
For policies and plans containing provisions inconsistent with this act, this
15
act first applies to policy or plan years beginning on the effective date of this
16
subsection, except as provided in sub. (
2
).
AB1121,5,21
17
(
2
)
For policies and plans that are affected by a collective bargaining
18
agreement containing provisions inconsistent with this act, this act first applies to
19
policy or plan years beginning on the effective date of this subsection or on the day
20
on which the collective bargaining agreement is newly established, extended,
21
modified, or renewed, whichever is later.
AB1121,4
22
Section
4
. Effective date.
AB1121,6,2
1
(
1
)
This act takes effect on the first day of the 4th month beginning after
2
publication.
AB1121,6,3
3
(end)
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proposaltext/2025/REG/AB1121
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true
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