THE BILL ITSELF
HB 1301
Coverage for Orthotics and Prosthetics Services
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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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authorizing the Agency for Health Care Administration
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to authorize and pay for specified orthotics and
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prosthetics services for Medicaid recipients;
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requiring the agency to seek federal approval and
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amend contracts as necessary to implement the act;
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creating ss. 627.64085, 627.6614, and 641.31079, F.S.;
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requiring individual health insurance policies; group,
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blanket, and franchise health insurance policies; and
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health maintenance contracts, respectively, to provide
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coverage for specified orthotics and prosthetics
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services; prohibiting health insurers and health
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maintenance organizations from denying claims under
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certain circumstances; requiring health insurers and
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health maintenance organizations to submit annual
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reports of specified information to the Office of
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Insurance Regulation; 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) The agency may authorize and pay for all of the
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following orthotics and prosthetics services:
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1. Orthoses and prostheses as those terms are defined in
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s. 468.80. Coverage must include payment for the model of an
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orthosis or a prosthesis which is deemed by the recipient's
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provider to be the most appropriate to meet the medical needs of
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the recipient to perform activities of daily living, essential
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job-related activities, and physical recreational activities,
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such as running, biking, swimming, strength training, and other
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activities that maximize the recipient's full body health and
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lower and upper limb function.
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2. All materials and components necessary to use the
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orthosis or prosthesis.
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3. Instruction on the use of the orthosis or prosthesis.
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4. Any necessary repairs or replacement of the orthosis or
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prosthesis.
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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) 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 for all of the following:
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(a) Orthoses and prostheses as those terms are defined in
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s. 468.80 if the insured's provider determines that an orthosis
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or a prosthesis is medically necessary for the insured to
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perform activities of daily living, essential job-related
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activities, and physical recreational activities, such as
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running, biking, swimming, strength training, and other
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activities that maximize the insured's full body health and
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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 insured'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 insured.
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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
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prosthesis, or part thereof, requires repairs that would cost
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more than 60 percent of the cost of a replacement orthosis or
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prosthesis or of the part thereof requiring replacement.
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A health insurer may require supporting documentation from an
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insured's provider to confirm the need for a replacement for an
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orthosis or a prosthesis that is less than 3 years old.
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(2) A health insurer may not deny a claim for an orthosis
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or a prosthesis for an insured with limb loss or limb absence
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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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(3) 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 the total number of claims submitted for orthotics
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and 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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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) 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 for all of the following:
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(a) Orthoses and prostheses as those terms are defined in
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s. 468.80 if the insured's provider determines that an orthosis
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or a prosthesis is medically necessary for the insured to
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perform activities of daily living, essential job-related
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activities, and physical recreational activities, such as
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running, biking, swimming, strength training, and other
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activities that maximize the insured's full body health and
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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 insured'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 insured.
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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
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prosthesis, or part thereof, requires repairs that would cost
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more than 60 percent of the cost of a replacement orthosis or
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prosthesis or of the part thereof requiring replacement.
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A health insurer may require supporting documentation from an
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insured's provider to confirm the need for a replacement for an
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orthosis or a prosthesis that is less than 3 years old.
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(2) A health insurer may not deny a claim for an orthosis
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or a prosthesis for an insured with limb loss or limb absence
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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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(3) 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 the total number of claims submitted for orthotics
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and 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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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) 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 for all of the following:
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(a) Orthoses and prostheses as those terms are defined in
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s. 468.80 if the subscriber's provider determines that an
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orthosis or a prosthesis is medically necessary for the
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subscriber to perform activities of daily living, essential job-
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related activities, and physical recreational activities, such
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as running, biking, swimming, strength training, and other
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activities that maximize the subscriber's full body health and
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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
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subscriber.
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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
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prosthesis, or part thereof, requires repairs that would cost
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more than 60 percent of the cost of a replacement orthosis or
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prosthesis or of the part thereof requiring replacement.
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A health maintenance organization may require supporting
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documentation from a subscriber's provider to confirm the need
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for a replacement for an orthosis or a prosthesis that is less
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than 3 years old.
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(2) A health maintenance organization may not deny a claim
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for an orthosis or a prosthesis for a subscriber with limb loss
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or limb absence which would otherwise be covered for a
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nondisabled person seeking medical or surgical intervention to
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restore or maintain the ability to perform the same type of
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physical function affected.
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(3) 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 the total number of claims
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submitted for orthotics and prosthetics services in the previous
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plan year and the total number of such claims that were paid,
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including the amount paid.
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Section 6. This act shall take effect July 1, 2026.