THE BILL ITSELF
CS/SB 1110
Coverage for Orthotics and Prosthetics Services
Florida Senate - 2026 CS for SB 1110 By the Committee on Banking and Insurance; and Senators Truenow and Smith 597-02756-26 20261110c1
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A bill to be entitled
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An act relating to coverage for orthotics and
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prosthetics services; amending s. 409.906, F.S.;
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defining the term “eligible individual”; authorizing
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the Agency for Health Care Administration to authorize
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and pay for specified orthotics and prosthetics
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services for Medicaid recipients who are eligible
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individuals; providing construction; requiring the
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agency to seek federal approval and amend contracts as
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necessary to implement the act; creating ss.
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627.64085, 627.6614, and 641.31079, F.S.; defining the
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term “eligible individual”; requiring individual
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health insurance policies; group, blanket, and
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franchise health insurance policies; and health
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maintenance contracts, respectively, to provide
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coverage for specified orthotics and prosthetics
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services for eligible individuals; authorizing health
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insurers and health maintenance organizations to
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require certain supporting documentation; prohibiting
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health insurers and health maintenance organizations
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from denying claims under certain circumstances;
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requiring health insurers and health maintenance
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organizations to submit annual reports of specified
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information to the Office of Insurance Regulation;
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providing construction; providing an effective date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Subsection (10) of section 409.906, Florida
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Statutes, is amended to read:
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409.906 Optional Medicaid services.—Subject to specific
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appropriations, the agency may make payments for services which
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are optional to the state under Title XIX of the Social Security
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Act and are furnished by Medicaid providers to recipients who
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are determined to be eligible on the dates on which the services
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were provided. Any optional service that is provided shall be
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provided only when medically necessary and in accordance with
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state and federal law. Optional services rendered by providers
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in mobile units to Medicaid recipients may be restricted or
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prohibited by the agency. Nothing in this section shall be
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construed to prevent or limit the agency from adjusting fees,
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reimbursement rates, lengths of stay, number of visits, or
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number of services, or making any other adjustments necessary to
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comply with the availability of moneys and any limitations or
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directions provided for in the General Appropriations Act or
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chapter 216. If necessary to safeguard the state’s systems of
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providing services to elderly and disabled persons and subject
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to the notice and review provisions of s. 216.177, the Governor
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may direct the Agency for Health Care Administration to amend
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the Medicaid state plan to delete the optional Medicaid service
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known as “Intermediate Care Facilities for the Developmentally
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Disabled.” Optional services may include:
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(10) DURABLE MEDICAL EQUIPMENT.—
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(a) The agency may authorize and pay for certain durable
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medical equipment and supplies provided to a Medicaid recipient
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as medically necessary.
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(b)1. As used in this paragraph, the term “eligible
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individual” means a Medicaid recipient who is:
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a. A child younger than 18 years of age;
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b. A dependent child as specified in s. 627.6562;
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c. An individual 26 years of age or younger who remains
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covered under a parent’s health insurance policy pursuant to s.
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627.6562; or
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d. An individual with a developmental disability as defined
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in s. 393.063.
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2. The agency may authorize and pay for all of the
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following orthotics and prosthetics services for eligible
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individuals:
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a. Orthoses and prostheses as those terms are defined in s.
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468.80. Coverage must include payment for:
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(I) The model of an orthosis or a prosthesis which is
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deemed by the eligible individual’s provider to be the most
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appropriate to meet the medical needs of the eligible individual
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to perform activities of daily living and essential job-related
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activities; and
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(II) When medically necessary, an orthosis or a prosthesis
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designed for physical or recreational activities that maximize
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the eligible individual’s full body health and lower and upper
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limb function.
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b. All materials and components necessary to use the
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orthosis or prosthesis.
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c. Instruction on the use of the orthosis or prosthesis.
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d. Any necessary repairs or replacement of the orthosis or
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prosthesis.
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3. This paragraph may not be construed to require Medicaid
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coverage of orthotics and prosthetics services specified herein
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for a Medicaid recipient who is not an eligible individual.
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Section 2. The Agency for Health Care Administration shall
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seek federal approval and amend contracts as necessary to
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implement the changes made to s. 409.906, Florida Statutes, by
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this act.
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Section 3. Section 627.64085, Florida Statutes, is created
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to read:
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627.64085 Orthotics and prosthetics services.—
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(1) As used in this section, the term “eligible individual”
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means an insured who is:
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a. A child younger than 18 years of age;
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b. A dependent child as specified in s. 627.6562;
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c. An individual 26 years of age or younger who remains
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covered under a parent’s health insurance policy pursuant to s.
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627.6562; or
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d. An individual with a developmental disability as defined
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in s. 393.063.
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(2) A health insurance policy issued, amended, delivered,
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or renewed in this state on or after July 1, 2026, must provide
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coverage of all of the following for eligible individuals:
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(a) Orthoses and prostheses as those terms are defined in
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s. 468.80 if the eligible individual’s provider determines that
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an orthosis or a prosthesis is medically necessary for the
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eligible individual to perform activities of daily living,
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essential job-related activities, and physical recreational
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activities, such as running, biking, swimming, strength
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training, and other activities that maximize the eligible
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individual’s full body health and lower and upper limb function.
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(b) Any replacement of the orthosis or prosthesis, or part
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thereof, without regard to continuous use or useful lifetime
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restrictions, if the eligible individual’s provider determines
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that it is medically necessary due to any of the following:
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1. A change in the physiological condition of the eligible
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individual.
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2. An irreparable change in the condition of the orthosis
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or prosthesis, or part thereof.
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3. A change in the condition of the orthosis or prosthesis,
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or part thereof, requires repairs that would cost more than 60
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percent of the cost of a replacement orthosis or prosthesis or
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of the part thereof requiring replacement.
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A health insurer may require supporting documentation from an
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eligible individual’s provider to confirm the need for a
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replacement for an orthosis or a prosthesis that is less than 3
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years old.
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(3) A health insurer may not deny a claim for an orthosis
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or a prosthesis as a medically necessary intervention to restore
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physical function for an eligible individual with a disability
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which would otherwise be covered for a nondisabled person
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seeking medical or surgical intervention to restore or maintain
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the ability to perform the same type of physical function
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affected.
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(4) Beginning July 1, 2027, and annually thereafter, each
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health insurer subject to this section shall submit a report to
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the Office of Insurance Regulation detailing the total number of
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claims submitted for orthotics and prosthetics services in the
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previous plan year and the total number of such claims that were
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paid, including the amount paid.
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(5) This section may not be construed to require coverage
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of orthotics or prosthetics services for an insured who is not
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an eligible individual.
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Section 4. Section 627.6614, Florida Statutes, is created
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to read:
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627.6614 Orthotics and prosthetics services.—
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(1) As used in this section, the term “eligible individual”
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means an insured who is:
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a. A child younger than 18 years of age;
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b. A dependent child as specified in s. 627.6562;
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c. An individual 26 years of age or younger who remains
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covered under a parent’s health insurance policy pursuant to s.
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627.6562; or
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d. An individual with a developmental disability as defined
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in s. 393.063.
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(2) A group, blanket, or franchise health insurance policy
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issued, amended, delivered, or renewed in this state on or after
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July 1, 2026, must provide coverage of all of the following for
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eligible individuals:
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(a) Orthoses and prostheses as those terms are defined in
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s. 468.80 if the eligible individual’s provider determines that
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an orthosis or a prosthesis is medically necessary for the
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eligible individual to perform activities of daily living,
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essential job-related activities, and physical recreational
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activities, such as running, biking, swimming, strength
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training, and other activities that maximize the eligible
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individual’s full body health and lower and upper limb function.
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(b) Any replacement of the orthosis or prosthesis, or part
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thereof, without regard to continuous use or useful lifetime
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restrictions, if the eligible individual’s provider determines
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that it is medically necessary due to any of the following:
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1. A change in the physiological condition of the eligible
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individual.
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2. An irreparable change in the condition of the orthosis
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or prosthesis, or part thereof.
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3. A change in the condition of the orthosis or prosthesis,
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or part thereof, requires repairs that would cost more than 60
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percent of the cost of a replacement orthosis or prosthesis or
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of the part thereof requiring replacement.
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A health insurer may require supporting documentation from an
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eligible individual’s provider to confirm the need for a
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replacement for an orthosis or a prosthesis that is less than 3
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years old.
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(3) A health insurer may not deny a claim for an orthosis
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or a prosthesis as a medically necessary intervention to restore
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physical function for an eligible individual with a disability
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which would otherwise be covered for a nondisabled person
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seeking medical or surgical intervention to restore or maintain
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the ability to perform the same type of physical function
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affected.
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(4) Beginning July 1, 2027, and annually thereafter, each
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health insurer subject to this section shall submit a report to
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the Office of Insurance Regulation detailing the total number of
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claims submitted for orthotics and prosthetics services in the
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previous plan year and the total number of such claims that were
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paid, including the amount paid.
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(5) This section may not be construed to require coverage
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of orthotics or prosthetics services for an insured who is not
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an eligible individual.
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Section 5. Section 641.31079, Florida Statutes, is created
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to read:
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641.31079 Orthotics and prosthetics services.—
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(1) As used in this section, the term “eligible individual”
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means a subscriber who is:
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a. A child younger than 18 years of age;
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b. A dependent child as specified in s. 627.6562;
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c. An individual 26 years of age or younger who remains
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covered under a parent’s health insurance policy pursuant to s.
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627.6562; or
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d. An individual with a developmental disability as defined
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in s. 393.063.
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(2) A health maintenance contract issued, amended,
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delivered, or renewed in this state on or after July 1, 2026,
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must provide coverage of all of the following for eligible
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individuals:
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(a) Orthoses and prostheses as those terms are defined in
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s. 468.80 if the eligible individual’s provider determines that
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an orthosis or a prosthesis is medically necessary for the
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eligible individual to perform activities of daily living,
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essential job-related activities, and physical recreational
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activities, such as running, biking, swimming, strength
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training, and other activities that maximize the eligible
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individual’s full body health and lower and upper limb function.
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(b) Any replacement of the orthosis or prosthesis, or part
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thereof, without regard to continuous use or useful lifetime
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restrictions, if the subscriber’s provider determines that it is
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medically necessary due to any of the following:
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1. A change in the physiological condition of the eligible
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individual.
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2. An irreparable change in the condition of the orthosis
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or prosthesis, or part thereof.
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3. A change in the condition of the orthosis or prosthesis,
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or part thereof, requires repairs that would cost more than 60
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percent of the cost of a replacement orthosis or prosthesis or
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of the part thereof requiring replacement.
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A health maintenance organization may require supporting
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documentation from an eligible individual’s provider to confirm
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the need for a replacement for an orthosis or a prosthesis that
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is less than 3 years old.
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(3) A health maintenance organization may not deny a claim
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for an orthosis or a prosthesis as a medically necessary
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intervention to restore physical function for an eligible
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individual with a disability which would otherwise be covered
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for a nondisabled person seeking medical or surgical
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intervention to restore or maintain the ability to perform the
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same type of physical function affected.
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(4) Beginning July 1, 2027, and annually thereafter, each
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health maintenance organization subject to this section shall
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submit a report to the Office of Insurance Regulation detailing
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the total number of claims submitted for orthotics and
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prosthetics services in the previous plan year and the total
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number of such claims that were paid, including the amount paid.
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(5) This section may not be construed to require coverage
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of orthotics or prosthetics services for a subscriber who is not
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an eligible individual.
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Section 6. This act shall take effect July 1, 2026.