,i  #aac? ,,congress  #a/ ,session  ,h4 
,r4 #cjbj  ,,9 ,,! ,,h\se ,,(           
,,repres5tatives  ,augu/ #b1 #bjac ,mr4 
,d5t 7= himself & ,mr4 ,&rews7 introduc$
 ! foll[+ bill2 :i* 0 ref]r$ to !       
,committee on ,en]gy & ,comm]ce1 & 9    
addition to ! ,committees on ,education 
& ! ,work=ce & ,ways & ,means1 = a p]iod
 to be subsequ5tly det]m9$ by ! ,speak]1
 9 ea* case = consid]ation ( su*        
provisions z fall )9 ! jurisdiction ( ! 
committee conc]n$  ,a ,,bill  ,to am5d !
 ,employee ,retirem5t ,income ,security 
,act ( #aigd1 ! ,public ,heal? ,s]vice  
,act1 & ! ,int]nal ,rev5ue ,code ( #aihf
 to provide p>ity "u gr\p & individual  
heal? plans & gr\p & individual heal?   
insurance cov]age = ! provision (       
b5efits = pro/hetics & cu/om or?otics & 
b5efits = o!r m$ical & surgical s]vices4
  #a4 ,%ort title ,?is ,act may be cit$ 
z ! ,insurance ,fairness = ,amputees    
,act4  #b4 ,f9d+s & purpose  7a7 ,f9d+s 
,congress makes ! foll[+ f9d+s3  7#a7   
,!re are m ?an #a1gjj1jjj p 9 ! ,unit$  

,/ates liv+ ) limb loss1 _m ( :om are   
appropriate c&idates = pro/hetic c>e4 ,a
 comp>able numb] exp]i5ce trauma1       
illness1 or disability t results 9      
musculoskeletal or neuromuscul>         
impairm5t ( ! limbs1 back1 & neck       
requir+ ! use ( or?otic c>e4  7#b7 ,e   
ye>1 !re are m ?an #acj1jjj p 9 ! ,unit$
 ,/ates :o und]go amputation proc$ures4 
7#c7 ,9 addition1 ,unit$ ,/ates milit>y 
p]sonnel s]v+ 9 ,iraq & ,afghani/an &   
ar\nd ! _w h su/a9$ traumatic injuries  
result+ 9 amputation & musculoskeletal  
or neuromuscul> injury4  7#d7 ,! numb] (
 amputations 9 ! ,unit$ ,/ates is       
project$ to increase 9 ! ye>s ahead due 
to ! ris+ incid5ce ( diabetes & o!r     
*ronic illness4  7#e7 ,^? exp]i5c+ limb 
loss & limb dysfunction c & want to     
rega9 _! lives z productive memb]s (    
society1 & pro/hetic & or?otic c>e (t5  
enables amputees & o!rs ) or?op$ic      
impairm5ts to cont9ue work+ & liv+      
productive lives4  7#f7 ,insurance      
companies (t5 re/rict cov]age =         

pro/hetic & or?otic devices & relat$    
s]vices ov] an individual's lifetime1   
:i* %ifts co/s onto individuals &       
consequ5tly to ! ,m$ic>e & ,m$icaid     
programs4  7#g7 ,tw5ty ,/ates h address$
 ?is problem & h pro/hetic or or?otic   
p>ity legislation1 :i* also is be+      
consid]$ actively 9 o!r ,/ates4  7#h7 ,!
 ,/ates 9 :i* pro/hetic or or?otic      
fairness 9 cov]age laws h be5 enact$ h  
f\nd !re to be m9imal or no increases 9 
insurance premiums & h r$uc$ ,m$ic>e &  
,m$icaid co/s4  7#i7 ,cov]age ( or?otic 
& pro/hetic devices & relat$ s]vices is 
only appropriate = individuals miss+ a  
limb or hav+ an or?op$ic condition 9 ne$
 ( treatm5t4 ,!re=e1 a fix$ population (
 individuals are c&idates = ^! devices &
 relat$ s]vices4  7#aj7 ,appropriate &  
timely treatm5t involv+ pro/hetic &     
or?otic devices & relat$ s]vices all[ p 
to rega9 heal? function1 preexi/+ "w1 & 
indep5d5t liv+4  7#aa7 ,pro/hetic &     
or?otic devices & relat$ s]vices are a  
di/9ct & sep>ate b5efit f ! durable     

m$ical equipm5t b5efit1 b ?is di/9ction 
(t5 is n recogniz$ z insur]s typically  
comb9e ^! b5efits "u a comb9$ limit4    
7#ab7 ,! ,pati5t ,protection & ,af=dable
 ,c>e ,act 7,public ,law #aaa-adh7 & !  
,heal? ,c>e & ,education ,reconciliation
 ,act 7,public ,law #aaa-aeb71 include  
rehabilitative & habilitative s]vices z 
an ess5tial heal? b5efit1 :i*           
legislative hi/ory %[s is int5d$ to cov]
 pro/hetic & or?otic devices & relat$   
s]vices4  7#ac7 ,! ,in/itute ( ,m$ic9e  
conclud$ t pro/hetic & or?otic devices &
 relat$ s]vices are cov]$ "u a typical  
employ] plan4  7#ad7 ,h[ev]1 :ile       
lifetime & annual doll> limitations on  
ess5tial heal? b5efits are prohibit$ "u 
! ,pati5t ,protection & ,af=dable ,c>e  
,act 7,public ,law #aaa-adh7 & ! ,heal? 
,c>e & ,education ,reconciliation ,act  
7,public ,law #aaa-aeb71 o!r te*niques  
to m9imize or elim9ate cov]age cont9ue  
to be us$ across ! c\ntry & are d5y+    
individuals access to m$ically necess>y 
pro/hetic & or?otic devices & relat$    

s]vices4  7b7 ,purpose ,x is ! purpose (
 ?is ,act to require t ea* gr\p &       
individual heal? plan & individual &    
gr\p heal? insurance cov]age t provides 
m$ical & surgical b5efits & also        
provides cov]age = pro/hetics or cu/om  
or?otics 7or bo?71 provide su* cov]age  
"u t]ms & conditions t are no less      
favorable ?an ! t]ms & conditions "u :i*
 m$ical & surgical b5efits are provid$  
"u su* plan4  #c4 ,pro/hetics & cu/om   
or?otics fairness 9 cov]age  7a7 ,,erisa
  7#a7 ,9 g5]al ,subp>t ,b ( "p #g (    
subtitle ,b ( title ,i ( ! ,employee    
,retirem5t ,income ,security ,act (     
#aigd 7#bi ,u4,s4,c4 #aahe et seq47 is  
am5d$ by add+ at ! end ! foll[+3  #gaf4 
,pro/hetics & cu/om or?otics fairness 9 
cov]age  7a7 ,9 g5]al ,9 ! case ( a gr\p
 heal? plan 7or heal? insurance cov]age 
(f]$ 9 connection ) a gr\p heal? plan7 t
 provides m$ical & surgical b5efits &   
also provides b5efits = pro/hetics or   
cu/om or?otics 7z def9$ "u p>agraphs    
7#a7 & 7#b7 ( subsection 7e77 7or bo?7--

  7#a7 su* b5efits = pro/hetics or cu/om
 or?otics 7or bo?7 "u ! plan 7or        
cov]age7 %all be provid$ "u t]ms &      
conditions t are no less favorable ?an !
 t]ms & conditions applicable to        
sub/antially all m$ical & surgical      
b5efits provid$ "u ! plan 7or cov]age72 
7#b7 su* b5efits = pro/hetics or cu/om  
or?otics 7or bo?7 "u ! plan 7or cov]age7
 may n be subject to sep>ate f9ancial   
requirem5ts 7z def9$ 9 subsection       
7d77#c77 t are applicable only ) respect
 to su* b5efits1 & any f9ancial         
requirem5ts applicable to su* b5efits   
%all be no m re/rictive ?an ! f9ancial  
requirem5ts applicable to sub/antially  
all m$ical & surgical b5efits provid$ "u
 ! plan 7or cov]age72 &  7#c7 any       
treatm5t limitations 7z def9$ 9         
subsection 7d77#d77 applicable to su*   
b5efits = pro/hetics or cu/om or?otics  
7or bo?7 "u ! plan 7or cov]age7 may n be
 m re/rictive ?an ! treatm5t limitations
 applicable to sub/antially all m$ical &
 surgical b5efits provid$ "u ! plan 7or 

cov]age74  7b7 ,pati5t access ,a gr\p   
heal? plan 7or heal? insurance cov]age  
(f]$ 9 connection ) a gr\p heal? plan7  
describ$ 9 subsection 7a7 t does n      
provide cov]age = b5efits outside ( a   
network %all ensure t su* provid]       
network is adequate to ensure enrollee  
access to pro/hetic & cu/om or?otic     
devices & relat$ s]vices provid$ by     
appropriately cr$5tial$ practition]s &  
accr$it$ suppli]s ( pro/hetics & cu/om  
or?otics4  7c7 ,additional requirem5ts  
7#a7 ,prior au?orization ,9 ! case ( a  
gr\p heal? plan 7or heal? insurance     
cov]age (f]$ 9 connection ) a gr\p heal?
 plan7 t requires1 z a condition (      
cov]age or paym5t = pro/hetics or cu/om 
or?otics 7or bo?7 "u ! plan 7or         
cov]age71 prior au?orization1 su* prior 
au?orization mu/ be requir$ 9 ! same    
mann] z prior au?orization is requir$ by
 ! plan 7or cov]age7 z a condition (    
cov]age or paym5t = all simil> m$ical & 
surgical b5efits provid$ "u ! plan 7or  
cov]age74  7#b7 ,limitation on b5efits  

,cov]age = requir$ b5efits = pro/hetics 
& cu/om or?otics "u ?is section may be  
limit$ to cov]age ( ! mo/ appropriate   
device or compon5t model t meets !      
m$ical requirem5ts ( ! pati5t1 z det]m9$
 by ! treat+ physician ( ! pati5t       
involv$4  7#c7 ,cov]age = repair or     
replacem5t ,b5efits = pro/hetics & cu/om
 or?otics requir$ "u ?is section %all   
include cov]age = ! repair or replacem5t
 ( pro/hetics & cu/om or?otics1 if !    
repair or replacem5t is due to normal   
we> & te>1 irrep>able damage1 a *ange 9 
! condition ( ! pati5t z det]m9$ by !   
treat+ physician1 or o!rwise det]m9$    
appropriate by ! treat+ physician ( !   
pati5t involv$4  7d7 ,def9itions ,9 ?is 
section3  7#a7 ,pro/hetics ,! t]m       
pro/hetics means ^? devices & compon5ts 
t may be us$ to replace1 9 :ole or 9 "p1
 an arm or leg1 z well z ! s]vices      
requir$ to d s & includes ext]nal brea/ 
pro/heses incid5t to ma/ectomy result+ f
 brea/ canc]4  7#b7 ,cu/om or?otics ,!  
t]m cu/om or?otics means ! foll[+3  7,a7

 ,cu/om-fabricat$ or?otics & relat$     
s]vices1 :i* include cu/om-fabricat$    
devices t are individually made = a     
specific pati5t1 z well z all s]vices & 
supplies t are m$ically necess>y = !    
effective use ( ! or?otic device &      
in/ruct+ ! pati5t 9 ! use ( ! device4   
,no o!r pati5t w\ld be able to use ?is  
p>ticul> or?osis4 ,a cu/om-fabricat$    
or?osis is a device :i* is fabricat$    
bas$ on cl9ically d]iv$ & rectifi$      
ca/+s1 trac+s1 measurem5ts1 or o!r      
images 7su* z x-rays7 ( ! body "p4 ,!   
fabrication may involve us+             
calculations1 templates & compon5t p>ts4
 ,?is process requires ! use ( basic    
mat]ials & involves sub/antial "w su* z 
vacuum =m+1 cutt+1 b5d+1 mold+1 sew+1   
drill+ & f9i%+ prior to fitt+ on !      
pati5t4 ,cu/om-fabricat$ devices may be 
furni%$ only by an appropriately        
cr$5tial$ 7c]tifi$ or lic5s$7           
practition] & accr$it$ suppli] 9        
,or?otics or ,pro/hetics4 ,su* devices &
 relat$ s]vices are repres5t$ by ! set (

 ,l-codes "u ! ,heal?c>e ,common        
,proc$ure ,cod+ ,sy/em describ+ ?is c>e 
li/$ on ! date ( enactm5t ( ?is section 
9 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices   
,transmittal #fef4  7,b7 ,cu/om-fitt$   
high or?otics & relat$ s]vices1 :i*     
include prefabricat$ devices t are      
manufactur$ ) no specific pati5t 9 m9d1 
b t are appropriately siz$1 adapt$1     
modifi$1 & configur$ 7) ! requir$ tools 
& equipm5t7 to a specific pati5t 9      
accordance ) a prescription1 & :i* no   
o!r pati5t w\ld be able to use1 z well z
 all s]vices & supplies t are m$ically  
necess>y = ! effective use ( ! or?otic  
device & in/ruct+ ! pati5t 9 ! use ( !  
device4 ,cu/om-fitt$ high devices may be
 furni%$ only by an appropriately       
cr$5tial$ 7c]tifi$ or lic5s$7           
practition] & accr$it$ suppli] 9        
,or?otics or ,pro/hetics4 ,su* devices &
 relat$ s]vices are repres5t$ by ! exi/+
 set ( ,l-codes "u ! ,heal?c>e ,common  
,proc$ure ,cod+ ,sy/em describ+ ?is c>e 
li/$ on ! date ( enactm5t ( ?is section 

9 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices   
,transmittal #fef4  ,= purposes (       
subp>agraphs 7,a7 & 7,b71 ,c5t]s =      
,m$ic>e  ,m$icaid ,s]vices ,transmittal 
#fef1 ^u modification or reissuance by !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices to 
reflect new code additions & cod+ *anges
 = pro/hetics & cu/om or?otics1 %all be 
! v]sion ( ! ,transmittal us$ = purposes
 ( su* subp>agraphs4  7#c7 ,f9ancial    
requirem5ts ,! t]m f9ancial requirem5ts 
includes d$uctibles1 co9surance1        
co-paym5ts1 o!r co/ %>+1 & limitations  
on ! total am\nt t may be paid by a     
p>ticipant or b5efici>y ) respect to    
b5efits "u ! plan or heal? insurance    
cov]age4  7#d7 ,treatm5t limitations ,! 
t]m treatm5t limitations includes limits
 on ! frequ5cy ( treatm5t1 numb] (      
visits1 specific prescrib$ compon5ts1   
limits t are m broadly applicable to    
durable m$ical equipm5t1 or o!r simil>  
limits on ! am\nt1 duration1 or scope ( 
treatm5t4  7e7 ,diff]5tiation f ,durable
 ,m$ical ,equipm5t ,= purposes ( ?is    

section1 pro/hetics & cu/om or?otics    
%all be treat$ z di/9ct f durable m$ical
 equipm5t4  4  7#b7 ,cl]ical am5dm5t ,! 
table ( cont5ts 9 section #a ( !        
,employee ,retirem5t ,income ,security  
,act ( #aigd is am5d$ by ins]t+ aft] !  
item relat+ to section #gad ! foll[+3   
,sec4 #gae4 ,additional m>ket re=ms4    
,sec4 #gaf4 ,pro/hetics & cu/om or?otics
 p>ity4  4  7b7 ,,phsa  7#a7 ,9 g5]al   
,title ,,xxvii ( ! ,public ,heal?       
,s]vice ,act is am5d$ by ins]t+ aft]    
section #bgbh ( su* ,act 7#db ,u4,s4,c4 
#cjj;gg-#bh71 z r$esignat$ by section   
#ajja7b7 ( ! ,pati5t ,protection &      
,af=dable ,c>e ,act 7,public ,law       
#aaa-adh71 ! foll[+3  #bgbi4 ,pro/hetics
 & cu/om or?otics p>ity  7a7 ,9 g5]al ,9
 ! case ( a gr\p heal? plan1 or a heal? 
insurance issu] (f]+ gr\p or individual 
heal? insurance cov]age1 t provides     
m$ical & surgical b5efits & also        
provides b5efits = pro/hetics or cu/om  
or?otics 7z def9$ "u p>agraphs 7#a7 &   
7#b7 ( subsection 7e77 7or bo?7--  7#a7 

su* b5efits = pro/hetics or cu/om       
or?otics 7or bo?7 "u ! plan or cov]age  
%all be provid$ "u t]ms & conditions t  
are no less favorable ?an ! t]ms &      
conditions applicable to sub/antially   
all m$ical & surgical b5efits provid$ "u
 ! plan or cov]age2  7#b7 su* b5efits = 
pro/hetics or cu/om or?otics 7or bo?7 "u
 ! plan or cov]age may n be subject to  
sep>ate f9ancial requirem5ts 7z def9$ 9 
subsection 7e77#b77 t are applicable    
only ) respect to su* b5efits1 & any    
f9ancial requirem5ts applicable to su*  
b5efits %all be no m re/rictive ?an !   
f9ancial requirem5ts applicable to      
sub/antially all m$ical & surgical      
b5efits provid$ "u ! plan or cov]age2 & 
7#c7 any treatm5t limitations 7z def9$ 9
 subsection 7e77#c77 applicable to su*  
b5efits = pro/hetics or cu/om or?otics  
7or bo?7 "u ! plan or cov]age may n be m
 re/rictive ?an ! treatm5t limitations  
applicable to sub/antially all m$ical & 
surgical b5efits provid$ "u ! plan or   
cov]age4  7b7 ,pati5t access ,a gr\p    

heal? plan1 or heal? insurance issu]    
(f]+ gr\p or individual heal? insurance 
cov]age1 describ$ 9 subsection 7a7 t    
does n provide cov]age = b5efits outside
 ( a network %all ensure t su* provid]  
network is adequate to ensure enrollee  
access to pro/hetic & cu/om or?otic     
devices & relat$ s]vices provid$ by     
appropriately cr$5tial$ practition]s &  
accr$it$ suppli]s ( pro/hetics & cu/om  
or?otics4  7c7 ,additional requirem5ts  
7#a7 ,prior au?orization ,9 ! case ( a  
gr\p heal? plan1 or heal? insurance     
issu] (f]+ gr\p or individual heal?     
insurance cov]age1 t requires1 z a      
condition ( cov]age or paym5t =         
pro/hetics or cu/om or?otics 7or bo?7 "u
 ! plan or cov]age1 prior au?orization1 
su* prior au?orization mu/ be requir$ 9 
! same mann] z prior au?orization is    
requir$ by ! plan or cov]age z a        
condition ( cov]age or paym5t = all     
simil> m$ical & surgical b5efits provid$
 "u ! plan or cov]age4  7#b7 ,limitation
 on b5efits ,cov]age = requir$ b5efits =

 pro/hetics & cu/om or?otics "u ?is     
section may be limit$ to cov]age ( ! mo/
 appropriate device or compon5t model t 
adequately meets ! m$ical requirem5ts ( 
! pati5t1 z det]m9$ by ! treat+         
physician ( ! pati5t involv$4  7#c7     
,cov]age = repair or replacem5t ,b5efits
 = pro/hetics & cu/om or?otics requir$  
"u ?is section %all include cov]age = ! 
repair or replacem5t ( pro/hetics &     
cu/om or?otics1 if ! repair or          
replacem5t is due to normal we> & te>1  
irrep>able damage1 a *ange 9 ! condition
 ( ! pati5t z det]m9$ by ! treat+       
physician1 or o!rwise det]m9$           
appropriate by ! treat+ physician ( !   
pati5t involv$4  7d7 ,def9itions ,9 ?is 
section3  7#a7 ,pro/hetics ,! t]m       
pro/hetics means ^? devices & compon5ts 
t may be us$ to replace1 9 :ole or 9 "p1
 an arm or leg1 z well z ! s]vices      
requir$ to d s & includes ext]nal brea/ 
pro/heses incid5t to ma/ectomy result+ f
 brea/ canc]4  7#b7 ,cu/om or?otics ,!  
t]m cu/om or?otics means ! foll[+3  7,a7

 ,cu/om-fabricat$ or?otics & relat$     
s]vices1 :i* include cu/om-fabricat$    
devices t are individually made = a     
specific pati5t1 z well z all s]vices & 
supplies t are m$ically necess>y = !    
effective use ( ! or?otic device &      
in/ruct+ ! pati5t 9 ! use ( ! device4   
,no o!r pati5t w\ld be able to use ?is  
p>ticul> or?osis4 ,a cu/om-fabricat$    
or?osis is a device :i* is fabricat$    
bas$ on cl9ically d]iv$ & rectifi$      
ca/+s1 trac+s1 measurem5ts1 or o!r      
images 7su* z x-rays7 ( ! body "p4 ,!   
fabrication may involve us+             
calculations1 templates & compon5t p>ts4
 ,?is process requires ! use ( basic    
mat]ials & involves sub/antial "w su* z 
vacuum =m+1 cutt+1 b5d+1 mold+1 sew+1   
drill+ & f9i%+ prior to fitt+ on !      
pati5t4 ,cu/om-fabricat$ devices may be 
furni%$ only by an appropriately        
cr$5tial$ 7c]tifi$ or lic5s$7           
practition] & accr$it$ suppli] 9        
,or?otics or ,pro/hetics4 ,su* devices &
 relat$ s]vices are repres5t$ by ! set (

 ,l-codes "u ! ,heal?c>e ,common        
,proc$ure ,cod+ ,sy/em describ+ ?is c>e 
li/$ on ! date ( enactm5t ( ?is section 
9 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices   
,transmittal #fef4  7,b7 ,cu/om-fitt$   
high or?otics & relat$ s]vices1 :i*     
include prefabricat$ devices t are      
manufactur$ ) no specific pati5t 9 m9d1 
b t are appropriately siz$1 adapt$1     
modifi$1 & configur$ 7) ! requir$ tools 
& equipm5t7 to a specific pati5t 9      
accordance ) a prescription1 & :i* no   
o!r pati5t w\ld be able to use1 z well z
 all s]vices & supplies t are m$ically  
necess>y = ! effective use ( ! or?otic  
device & in/ruct+ ! pati5t 9 ! use ( !  
device4 ,cu/om-fitt$ high devices may be
 furni%$ only by an appropriately       
cr$5tial$ 7c]tifi$ or lic5s$7           
practition] & accr$it$ suppli] 9        
,or?otics or ,pro/hetics4 ,su* devices &
 relat$ s]vices are repres5t$ by ! exi/+
 set ( ,l-codes "u ! ,heal?c>e ,common  
,proc$ure ,cod+ ,sy/em describ+ ?is c>e 
li/$ on ! date ( enactm5t ( ?is section 

9 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices   
,transmittal #fef4  ,= purposes (       
subp>agraphs 7,a7 & 7,b71 ,c5t]s =      
,m$ic>e  ,m$icaid ,s]vices ,transmittal 
#fef1 ^u modification or reissuance by !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices to 
reflect new code additions & cod+ *anges
 = pro/hetics & cu/om or?otics1 %all be 
! v]sion ( ! ,transmittal us$ = purposes
 ( su* subp>agraphs4  7#c7 ,f9ancial    
requirem5ts ,! t]m f9ancial requirem5ts 
includes d$uctibles1 co9surance1        
co-paym5ts1 o!r co/ %>+1 & limitations  
on ! total am\nt t may be paid by a     
p>ticipant or b5efici>y ) respect to    
b5efits "u ! plan or heal? insurance    
cov]age4  7#d7 ,treatm5t limitations ,! 
t]m treatm5t limitations includes limits
 on ! frequ5cy ( treatm5t1 numb] (      
visits1 specific prescrib$ compon5ts1 & 
limits t are m broadly applicable to    
durable m$ical equipm5t1 or o!r simil>  
limits on ! am\nt1 duration1 or scope ( 
treatm5t4  7e7 ,diff]5tiation f ,durable
 ,m$ical ,equipm5t ,= purposes ( ?is    

section1 pro/hetics & cu/om or?otics    
%all be treat$ z di/9ct f durable m$ical
 equipm5t4  4  7#b7 ,application to     
individual heal? insurance cov]age be=e 
#bjad ,= purposes ( apply+ section #bgbi
 ( ! ,public ,heal? ,s]vice ,act1 z     
ins]t$ by p>agraph 7#a71 to individual  
heal? insurance cov]age be=e #bjad1 !   
provisions ( su* section %all be treat$ 
z also includ$ "u "p ,b ( title ,,xxvii 
( ! ,public ,heal? ,s]vice ,act4  7c7   
,int]nal ,rev5ue ,code ,sub*apt] ,b (   
*apt] #ajj ( subtitle ,k ( ! ,int]nal   
,rev5ue ,code ( #aihf is am5d$ by add+  
aft] section #ihac ! foll[+3  #ihad4    
,pro/hetics & cu/om or?otics fairness 9 
cov]age  7a7 ,9 g5]al ,9 ! case ( a gr\p
 heal? plan 7or heal? insurance cov]age 
(f]$ 9 connection ) a gr\p heal? plan7 t
 provides m$ical & surgical b5efits &   
also provides b5efits = pro/hetics or   
cu/om or?otics 7z def9$ "u p>agraphs    
7#a7 & 7#b7 ( subsection 7e77 7or bo?7--
  7#a7 su* b5efits = pro/hetics or cu/om
 or?otics 7or bo?7 "u ! plan 7or        

cov]age7 %all be provid$ "u t]ms &      
conditions t are no less favorable ?an !
 t]ms & conditions applicable to        
sub/antially all m$ical & surgical      
b5efits provid$ "u ! plan 7or cov]age72 
7#b7 su* b5efits = pro/hetics or cu/om  
or?otics 7or bo?7 "u ! plan 7or cov]age7
 may n be subject to sep>ate f9ancial   
requirem5ts 7z def9$ 9 subsection       
7e77#b77 t are applicable only ) respect
 to su* b5efits1 & any f9ancial         
requirem5ts applicable to su* b5efits   
%all be no m re/rictive ?an ! f9ancial  
requirem5ts applicable to sub/antially  
all m$ical & surgical b5efits provid$ "u
 ! plan 7or cov]age72 &  7#c7 any       
treatm5t limitations 7z def9$ 9         
subsection 7e77#c77 applicable to su*   
b5efits = pro/hetics or cu/om or?otics  
7or bo?7 "u ! plan 7or cov]age7 may n be
 m re/rictive ?an ! treatm5t limitations
 applicable to sub/antially all m$ical &
 surgical b5efits provid$ "u ! plan 7or 
cov]age74  7b7 ,pati5t access ,a gr\p   
heal? plan 7or heal? insurance cov]age  

(f]$ 9 connection ) a gr\p heal? plan7  
describ$ 9 subsection 7a7 t does n      
provide cov]age = b5efits outside ( a   
network %all ensure t su* provid]       
network is adequate to ensure enrollee  
access to pro/hetic & cu/om or?otic     
devices & relat$ s]vices provid$ by     
appropriately cr$5tial$ practition]s &  
accr$it$ suppli]s ( pro/hetics & cu/om  
or?otics4  7c7 ,additional requirem5ts  
7#a7 ,prior au?orization ,9 ! case ( a  
gr\p heal? plan 7or heal? insurance     
cov]age (f]$ 9 connection ) a gr\p heal?
 plan7 t requires1 z a condition (      
cov]age or paym5t = pro/hetics or cu/om 
or?otics 7or bo?7 "u ! plan 7or         
cov]age71 prior au?orization1 su* prior 
au?orization mu/ be requir$ 9 ! same    
mann] z prior au?orization is requir$ by
 ! plan 7or cov]age7 z a condition (    
cov]age or paym5t = all simil> m$ical & 
surgical b5efits provid$ "u ! plan 7or  
cov]age74  7#b7 ,limitation on b5efits  
,cov]age = requir$ b5efits = pro/hetics 
& cu/om or?otics "u ?is section may be  

limit$ to cov]age ( ! mo/ appropriate   
device or compon5t model t meets !      
m$ical requirem5ts ( ! pati5t1 z det]m9$
 by ! treat+ physician ( ! pati5t       
involv$4  7#c7 ,cov]age = repair or     
replacem5t ,b5efits = pro/hetics & cu/om
 or?otics requir$ "u ?is section %all   
include cov]age = ! repair or replacem5t
 ( pro/hetics & cu/om or?otics1 if !    
repair or replacem5t is due to normal   
we> & te>1 irrep>able damage1 a *ange 9 
! condition ( ! pati5t z det]m9$ by !   
treat+ physician1 or o!rwise det]m9$    
appropriate by ! treat+ physician ( !   
pati5t involv$4  7#d7 ,assi/ance to     
enrollees ,! ,secret>y ( ! ,treasury1 9 
consultation ) ! ,secret>y ( ,heal? &   
,human ,s]vices1 %all provide assi/ance 
to enrollees "u plans or cov]age to :i* 
! am5dm5t made by section #c apply ) any
 que/ions or problems ) respect to      
compliance ) ! requirem5ts ( su*        
am5dm5t4  7#e7 ,audits ,! ,secret>y ( ! 
,treasury1 9 consultation ) ! ,secret>y 
( ,heal? & ,human ,s]vices1 %all provide

 = ! conduct ( r&om audits ( gr\p heal? 
plans 7& heal? insurance cov]age (f]$ 9 
connection ) su* plans7 to ensure t su* 
plans 7or cov]age7 are 9 compliance ) ! 
am5dm5ts made by section 7#c74  7d7     
,def9itions ,9 ?is section3  7#a7       
,pro/hetics ,! t]m pro/hetics means ^?  
devices & compon5ts t may be us$ to     
replace1 9 :ole or 9 "p1 an arm or leg1 
z well z ! s]vices requir$ to d s &     
includes ext]nal brea/ pro/heses incid5t
 to ma/ectomy result+ f brea/ canc]4    
7#b7 ,cu/om or?otics ,! t]m cu/om       
or?otics means ! foll[+3  7,a7          
,cu/om-fabricat$ or?otics & relat$      
s]vices1 :i* include cu/om-fabricat$    
devices t are individually made = a     
specific pati5t1 z well z all s]vices & 
supplies t are m$ically necess>y = !    
effective use ( ! or?otic device &      
in/ruct+ ! pati5t 9 ! use ( ! device4   
,no o!r pati5t w\ld be able to use ?is  
p>ticul> or?osis4 ,a cu/om-fabricat$    
or?osis is a device :i* is fabricat$    
bas$ on cl9ically d]iv$ & rectifi$      

ca/+s1 trac+s1 measurem5ts1 or o!r      
images 7su* z x-rays7 ( ! body "p4 ,!   
fabrication may involve us+             
calculations1 templates & compon5t p>ts4
 ,?is process requires ! use ( basic    
mat]ials & involves sub/antial "w su* z 
vacuum =m+1 cutt+1 b5d+1 mold+1 sew+1   
drill+ & f9i%+ prior to fitt+ on !      
pati5t4 ,cu/om-fabricat$ devices may be 
furni%$ only by an appropriately        
cr$5tial$ 7c]tifi$ or lic5s$7           
practition] & accr$it$ suppli] 9        
,or?otics or ,pro/hetics4 ,su* devices &
 relat$ s]vices are repres5t$ by ! set (
 ,l-codes "u ! ,heal?c>e ,common        
,proc$ure ,cod+ ,sy/em describ+ ?is c>e 
li/$ on ! date ( enactm5t ( ?is section 
9 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices   
,transmittal #fef4  7,b7 ,cu/om-fitt$   
high or?otics & relat$ s]vices1 :i*     
include prefabricat$ devices t are      
manufactur$ ) no specific pati5t 9 m9d1 
b t are appropriately siz$1 adapt$1     
modifi$1 & configur$ 7) ! requir$ tools 
& equipm5t7 to a specific pati5t 9      

accordance ) a prescription1 & :i* no   
o!r pati5t w\ld be able to use1 z well z
 all s]vices & supplies t are m$ically  
necess>y = ! effective use ( ! or?otic  
device & in/ruct+ ! pati5t 9 ! use ( !  
device4 ,cu/om-fitt$ high devices may be
 furni%$ only by an appropriately       
cr$5tial$ 7c]tifi$ or lic5s$7           
practition] & accr$it$ suppli] 9        
,or?otics or ,pro/hetics4 ,su* devices &
 relat$ s]vices are repres5t$ by ! exi/+
 set ( ,l-codes "u ! ,heal?c>e ,common  
,proc$ure ,cod+ ,sy/em describ+ ?is c>e 
li/$ on ! date ( enactm5t ( ?is section 
9 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices   
,transmittal #fef4  ,= purposes (       
subp>agraphs 7,a7 & 7,b71 ,c5t]s =      
,m$ic>e  ,m$icaid ,s]vices ,transmittal 
#fef1 ^u modification or reissuance by !
 ,c5t]s = ,m$ic>e  ,m$icaid ,s]vices to 
reflect new code additions & cod+ *anges
 = pro/hetics & cu/om or?otics1 %all be 
! v]sion ( ! ,transmittal us$ = purposes
 ( su* subp>agraphs4  7#c7 ,f9ancial    
requirem5ts ,! t]m f9ancial requirem5ts 

includes d$uctibles1 co9surance1        
co-paym5ts1 o!r co/ %>+1 & limitations  
on ! total am\nt t may be paid by a     
p>ticipant or b5efici>y ) respect to    
b5efits "u ! plan or heal? insurance    
cov]age4  7#d7 ,treatm5t limitations ,! 
t]m treatm5t limitations includes limits
 on ! frequ5cy ( treatm5t1 numb] (      
visits1 specific prescrib$ compon5ts1 or
 o!r simil> limits on ! scope or        
duration ( treatm5t4  7e7 ,diff]5tiation
 f ,durable ,m$ical ,equipm5t ,=        
purposes ( ?is section1 pro/hetics &    
cu/om or?otics %all be treat$ z di/9ct f
 durable m$ical equipm5t4  4  7d7       
,effective date ,! am5dm5ts made by ?is 
section %all apply ) respect to plan    
ye>s beg9n+ on or aft] ! date ( !       
enactm5t ( ?is section & ) respect to   
heal? insurance cov]age issu$ on or aft]
 su* date4  #d4 ,updat+ /&>d def9itions 
to include pro/hetics & cu/om or?otics  
7a7 ,9 g5]al ,section #bgae7;g77#c7 ( ! 
,public ,heal? ,s]vice ,act 7#db        
,u4,s4,c4 #cjj;gg-#ae7;g77#c77 is am5d$ 

by ins]t+ pro/hetics1 cu/om or?otics1   
aft] em]g5cy m$ical transportation14    
7b7 ,pro/hetics2 cu/om or?otics ,9      
develop+ /&>ds = ! def9itions ( ! t]ms  
pro/hetics & cu/om or?otics pursuant to 
! am5dm5t made by subsection 7a71 !     
,secret>y %all ensure t su* def9itions  
are consi/5t ) ! def9itions ( su* t]ms 9
 section #bgbi7;d7 ( ! ,public ,heal?   
,s]vice ,act 7z add$ by section #c7;b7 (
 ?is ,act74  #e4 ,f$]al adm9i/rative    
responsibilities  7a7 ,assi/ance to     
enrollees ,! ,secret>y ( ,labor1 9      
consultation ) ! ,secret>y ( ,heal? &   
,human ,s]vices1 %all provide assi/ance 
to enrollees "u gr\p heal? plans 7&     
heal? insurance cov]age (f]$ 9          
connection ) su* plans7 to :i* !        
am5dm5ts made by section #c apply ) any 
que/ions or problems ) respect to       
compliance ) ! requirem5ts ( su*        
am5dm5ts4  7b7 ,audits ,! ,secret>y (   
,labor1 9 consultation ) ! ,secret>y (  
,heal? & ,human ,s]vices1 %all provide =
 ! conduct ( r&om audits ( gr\p heal?   

plans 7& heal? insurance cov]age (f]$ 9 
connection ) su* plans7 to ensure t su* 
plans 7or cov]age7 are 9 compliance ) ! 
am5dm5ts made by section #c4  7c7       
,regulations ,n lat] ?an #a ye> aft] !  
date ( ! enactm5t ( ?is ,act1 !         
,secret>y ( ,labor1 9 consultation ) !  
,secret>y ( ,heal? & ,human ,s]vices1   
%all promulgate f9al regulations to c>ry
 out ?is ,act & ! am5dm5ts made by ?is  
,act4  7d7 ,def9itions ,9 ?is section3  
7#a7 ,gr\p ,heal? ,plan ,! t]m gr\p     
heal? plan has ! mean+ giv5 su* t]m 9   
section #gcc7;a7 ( ! ,employee          
,retirem5t & ,income ,security ,act (   
#aigd 7#bi ,u4,s4,c4 #aaia;b7a774  7#b7 
,heal? ,insurance ,cov]age ,! t]m heal? 
insurance cov]age has ! mean+ giv5 su*  
t]m 9 section #gcc7;b77#a7 ( su* ,act   
7#bi ,u4,s4,c4 #aaia;b7b77#a774