Florida Senate - 2024 SB 828
By Senator Collins
14-00538-24 2024828__
1 A bill to be entitled
2 An act relating to coverage for orthotics and
3 prosthetics services; amending s. 409.906, F.S.;
4 authorizing the Agency for Health Care Administration
5 to pay for specified orthotics and prosthetics
6 services for Medicaid recipients; requiring the agency
7 to seek federal approval and amend contracts as
8 necessary to implement the act; creating ss.
9 627.64085, 627.6614, and 641.31079, F.S.; requiring
10 individual health insurance policies, group, blanket,
11 and franchise health insurance policies, and health
12 maintenance contracts, respectively, to provide
13 coverage for specified orthotics and prosthetics
14 services; prohibiting health insurers and health
15 maintenance organizations from denying claims under
16 certain circumstances; requiring health insurers and
17 health maintenance organizations to submit annual
18 reports of specified information to the Office of
19 Insurance Regulation; providing an effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Subsection (10) of section 409.906, Florida
24 Statutes, is amended to read:
25 409.906 Optional Medicaid services.—Subject to specific
26 appropriations, the agency may make payments for services which
27 are optional to the state under Title XIX of the Social Security
28 Act and are furnished by Medicaid providers to recipients who
29 are determined to be eligible on the dates on which the services
30 were provided. Any optional service that is provided shall be
31 provided only when medically necessary and in accordance with
32 state and federal law. Optional services rendered by providers
33 in mobile units to Medicaid recipients may be restricted or
34 prohibited by the agency. Nothing in this section shall be
35 construed to prevent or limit the agency from adjusting fees,
36 reimbursement rates, lengths of stay, number of visits, or
37 number of services, or making any other adjustments necessary to
38 comply with the availability of moneys and any limitations or
39 directions provided for in the General Appropriations Act or
40 chapter 216. If necessary to safeguard the state’s systems of
41 providing services to elderly and disabled persons and subject
42 to the notice and review provisions of s. 216.177, the Governor
43 may direct the Agency for Health Care Administration to amend
44 the Medicaid state plan to delete the optional Medicaid service
45 known as “Intermediate Care Facilities for the Developmentally
46 Disabled.” Optional services may include:
47 (10) DURABLE MEDICAL EQUIPMENT.—
48 (a) The agency may authorize and pay for certain durable
49 medical equipment and supplies provided to a Medicaid recipient
50 as medically necessary.
51 (b) The agency may authorize and pay for all of the
52 following orthotics and prosthetics services:
53 1. Orthoses and prostheses as those terms are defined in s.
54 468.80. Coverage must include payment for the model of an
55 orthosis or a prosthesis which is deemed by the recipient’s
56 provider to be the most appropriate to meet the medical needs of
57 the recipient to perform activities of daily living, essential
58 job-related activities, and physical recreational activities
59 that maximize the recipient’s full body health and lower and
60 upper limb function.
61 2. All materials and components necessary to use the
62 orthosis or prosthesis.
63 3. Instruction on the use of the orthosis or prosthesis.
64 4. Any necessary repairs or replacement of the orthosis or
65 prosthesis.
66 Section 2. The Agency for Health Care Administration shall
67 seek federal approval and amend contracts as necessary to
68 implement the changes made to s. 409.906, Florida Statutes, by
69 this act.
70 Section 3. Section 627.64085, Florida Statutes, is created
71 to read:
72 627.64085 Orthotics and prosthetics services.—
73 (1) A health insurance policy issued, amended, delivered,
74 or renewed in this state on or after July 1, 2024, must provide
75 coverage for all of the following:
76 (a) Orthoses and prostheses as those terms are defined in
77 s. 468.80 if the insured’s provider determines that an orthosis
78 or a prosthesis is medically necessary for the insured to
79 perform activities of daily living, essential job-related
80 activities, and physical recreational activities, such as
81 running, biking, swimming, strength training, and other
82 activities that maximize the insured’s full body health and
83 lower and upper limb function.
84 (b) Any replacement of the orthosis or prosthesis, or part
85 thereof, without regard to continuous use or useful lifetime
86 restrictions, if the insured’s provider determines that it is
87 medically necessary due to any of the following:
88 1. A change in the physiological condition of the insured.
89 2. An irreparable change in the condition of the orthosis
90 or prosthesis, or part thereof.
91 3. The condition of the device, or part thereof, requires
92 repairs and the cost of the repairs would be more than 60
93 percent of the cost of a replacement orthosis or prosthesis or
94 of the part thereof requiring replacement.
95
96 A health insurer may require supporting documentation from an
97 insured’s provider to confirm the need for a replacement for an
98 orthosis or a prosthesis that is less than 3 years old.
99 (2) A health insurer may not deny a claim for an orthosis
100 or a prosthesis for an insured with limb loss or limb absence
101 which would otherwise be covered for a nondisabled person
102 seeking medical or surgical intervention to restore or maintain
103 the ability to perform the same type of physical function
104 affected.
105 (3) Beginning July 1, 2025, and annually thereafter, each
106 health insurer subject to this section shall submit a report to
107 the office of the total number of claims submitted for orthoses
108 and prostheses services in the previous plan year and the total
109 number of such claims that were paid, including the amount paid.
110 Section 4. Section 627.6614, Florida Statutes, is created
111 to read:
112 627.6614 Orthotics and prosthetics services.—
113 (1) A group, blanket, or franchise health insurance policy
114 issued, amended, delivered, or renewed in this state on or after
115 July 1, 2024, must provide coverage for all of the following:
116 (a) Orthoses and prostheses as those terms are defined in
117 s. 468.80 if the insured’s provider determines that an orthosis
118 or a prosthesis is medically necessary for the insured to
119 perform activities of daily living, essential job-related
120 activities, and physical recreational activities, such as
121 running, biking, swimming, strength training, and other
122 activities that maximize the insured’s full body health and
123 lower and upper limb function.
124 (b) Any replacement of the orthosis or prosthesis, or part
125 thereof, without regard to continuous use or useful lifetime
126 restrictions, if the insured’s provider determines that it is
127 medically necessary due to any of the following:
128 1. A change in the physiological condition of the insured.
129 2. An irreparable change in the condition of the orthosis
130 or prosthesis, or part thereof.
131 3. The condition of the device, or part thereof, requires
132 repairs and the cost of the repairs would be more than 60
133 percent of the cost of a replacement orthosis or prosthesis or
134 of the part thereof requiring replacement.
135
136 A health insurer may require supporting documentation from an
137 insured’s provider to confirm the need for a replacement for an
138 orthosis or a prosthesis that is less than 3 years old.
139 (2) A health insurer may not deny a claim for an orthosis
140 or a prosthesis for an insured with limb loss or limb absence
141 which would otherwise be covered for a nondisabled person
142 seeking medical or surgical intervention to restore or maintain
143 the ability to perform the same type of physical function
144 affected.
145 (3) Beginning July 1, 2025, and annually thereafter, each
146 health insurer subject to this section shall submit a report to
147 the office of the total number of claims submitted for orthoses
148 and prostheses services in the previous plan year and the total
149 number of such claims that were paid, including the amount paid.
150 Section 5. Section 641.31079, Florida Statutes, is created
151 to read:
152 641.31079 Orthotics and prosthetics services.—
153 (1) A health maintenance contract issued, amended,
154 delivered, or renewed in this state on or after July 1, 2024,
155 must provide coverage for all of the following:
156 (a) Orthoses and prostheses as those terms are defined in
157 s. 468.80 if the subscriber’s provider determines that an
158 orthosis or a prosthesis is medically necessary for the
159 subscriber to perform activities of daily living, essential job
160 related activities, and physical recreational activities, such
161 as running, biking, swimming, strength training, and other
162 activities that maximize the subscriber’s full body health and
163 lower and upper limb function.
164 (b) Any replacement of the orthosis or prosthesis, or part
165 thereof, without regard to continuous use or useful lifetime
166 restrictions, if the subscriber’s provider determines that it is
167 medically necessary due to any of the following:
168 1. A change in the physiological condition of the
169 subscriber.
170 2. An irreparable change in the condition of the orthosis
171 or prosthesis, or part thereof.
172 3. The condition of the device, or part thereof, requires
173 repairs and the cost of the repairs would be more than 60
174 percent of the cost of a replacement orthosis or prosthesis or
175 of the part thereof requiring replacement.
176
177 A health maintenance organization may require supporting
178 documentation from a subscriber’s provider to confirm the need
179 for a replacement for an orthosis or a prosthesis that is less
180 than 3 years old.
181 (2) A health maintenance organization may not deny a claim
182 for an orthosis or a prosthesis for a subscriber with limb loss
183 or limb absence which would otherwise be covered for a
184 nondisabled person seeking medical or surgical intervention to
185 restore or maintain the ability to perform the same type of
186 physical function affected.
187 (3) Beginning July 1, 2025, and annually thereafter, each
188 health maintenance organization subject to this section shall
189 submit a report to the office of the total number of claims
190 submitted for orthoses and prostheses services in the previous
191 plan year and the total number of such claims that were paid,
192 including the amount paid.
193 Section 6. This act shall take effect July 1, 2024.