Bill Summary – FastDemocracy

       Florida Senate - 2024                                     SB 828



       By Senator Collins





       14-00538-24                                            2024828__
                      A bill to be entitled                      
       An act relating to coverage for orthotics and
       prosthetics services; amending s. 409.906, F.S.;
       authorizing the Agency for Health Care Administration
       to pay for specified orthotics and prosthetics
       services for Medicaid recipients; requiring the agency
       to seek federal approval and amend contracts as
       necessary to implement the act; creating ss.
       627.64085, 627.6614, and 641.31079, F.S.; requiring
       individual health insurance policies, group, blanket,
       and franchise health insurance policies, and health
       maintenance contracts, respectively, to provide
       coverage for specified orthotics and prosthetics
       services; prohibiting health insurers and health
       maintenance organizations from denying claims under
       certain circumstances; requiring health insurers and
       health maintenance organizations to submit annual
       reports of specified information to the Office of
       Insurance Regulation; providing an effective date.
        
Be It Enacted by the Legislature of the State of Florida:

       Section 1. Subsection (10) of section 409.906, Florida
Statutes, is amended to read:
       409.906 Optional Medicaid services.—Subject to specific
appropriations, the agency may make payments for services which
are optional to the state under Title XIX of the Social Security
Act and are furnished by Medicaid providers to recipients who
are determined to be eligible on the dates on which the services
were provided. Any optional service that is provided shall be
provided only when medically necessary and in accordance with
state and federal law. Optional services rendered by providers
in mobile units to Medicaid recipients may be restricted or
prohibited by the agency. Nothing in this section shall be
construed to prevent or limit the agency from adjusting fees,
reimbursement rates, lengths of stay, number of visits, or
number of services, or making any other adjustments necessary to
comply with the availability of moneys and any limitations or
directions provided for in the General Appropriations Act or
chapter 216. If necessary to safeguard the state’s systems of
providing services to elderly and disabled persons and subject
to the notice and review provisions of s. 216.177, the Governor
may direct the Agency for Health Care Administration to amend
the Medicaid state plan to delete the optional Medicaid service
known as “Intermediate Care Facilities for the Developmentally
Disabled.” Optional services may include:
       (10) DURABLE MEDICAL EQUIPMENT.—
       (a) The agency may authorize and pay for certain durable
medical equipment and supplies provided to a Medicaid recipient
as medically necessary.
       (b) The agency may authorize and pay for all of the
following orthotics and prosthetics services:
       1. Orthoses and prostheses as those terms are defined in s.
468.80. Coverage must include payment for the model of an
orthosis or a prosthesis which is deemed by the recipient’s
provider to be the most appropriate to meet the medical needs of
the recipient to perform activities of daily living, essential
job-related activities, and physical recreational activities
that maximize the recipient’s full body health and lower and
upper limb function.
       2. All materials and components necessary to use the
orthosis or prosthesis.
       3. Instruction on the use of the orthosis or prosthesis.
       4. Any necessary repairs or replacement of the orthosis or
prosthesis.
       Section 2. The Agency for Health Care Administration shall
seek federal approval and amend contracts as necessary to
implement the changes made to s. 409.906, Florida Statutes, by
this act.
       Section 3. Section 627.64085, Florida Statutes, is created
to read:
       627.64085 Orthotics and prosthetics services.—
       (1) A health insurance policy issued, amended, delivered,
or renewed in this state on or after July 1, 2024, must provide
coverage for all of the following:
       (a) Orthoses and prostheses as those terms are defined in
s. 468.80 if the insured’s provider determines that an orthosis
or a prosthesis is medically necessary for the insured to
perform activities of daily living, essential job-related
activities, and physical recreational activities, such as
running, biking, swimming, strength training, and other
activities that maximize the insured’s full body health and
lower and upper limb function.
       (b) Any replacement of the orthosis or prosthesis, or part
thereof, without regard to continuous use or useful lifetime
restrictions, if the insured’s provider determines that it is
medically necessary due to any of the following:
       1. A change in the physiological condition of the insured.
       2. An irreparable change in the condition of the orthosis
or prosthesis, or part thereof.
       3. The condition of the device, or part thereof, requires
repairs and the cost of the repairs would be more than 60
percent of the cost of a replacement orthosis or prosthesis or
of the part thereof requiring replacement.

A health insurer may require supporting documentation from an
insured’s provider to confirm the need for a replacement for an
orthosis or a prosthesis that is less than 3 years old.
       (2) A health insurer may not deny a claim for an orthosis
or a prosthesis for an insured with limb loss or limb absence
which would otherwise be covered for a nondisabled person
seeking medical or surgical intervention to restore or maintain
the ability to perform the same type of physical function
affected.
       (3) Beginning July 1, 2025, and annually thereafter, each
health insurer subject to this section shall submit a report to
the office of the total number of claims submitted for orthoses
and prostheses services in the previous plan year and the total
number of such claims that were paid, including the amount paid.
       Section 4. Section 627.6614, Florida Statutes, is created
to read:
       627.6614 Orthotics and prosthetics services.—
       (1) A group, blanket, or franchise health insurance policy
issued, amended, delivered, or renewed in this state on or after
July 1, 2024, must provide coverage for all of the following:
       (a) Orthoses and prostheses as those terms are defined in
s. 468.80 if the insured’s provider determines that an orthosis
or a prosthesis is medically necessary for the insured to
perform activities of daily living, essential job-related
activities, and physical recreational activities, such as
running, biking, swimming, strength training, and other
activities that maximize the insured’s full body health and
lower and upper limb function.
       (b) Any replacement of the orthosis or prosthesis, or part
thereof, without regard to continuous use or useful lifetime
restrictions, if the insured’s provider determines that it is
medically necessary due to any of the following:
       1. A change in the physiological condition of the insured.
       2. An irreparable change in the condition of the orthosis
or prosthesis, or part thereof.
       3. The condition of the device, or part thereof, requires
repairs and the cost of the repairs would be more than 60
percent of the cost of a replacement orthosis or prosthesis or
of the part thereof requiring replacement.

A health insurer may require supporting documentation from an
insured’s provider to confirm the need for a replacement for an
orthosis or a prosthesis that is less than 3 years old.
       (2) A health insurer may not deny a claim for an orthosis
or a prosthesis for an insured with limb loss or limb absence
which would otherwise be covered for a nondisabled person
seeking medical or surgical intervention to restore or maintain
the ability to perform the same type of physical function
affected.
       (3) Beginning July 1, 2025, and annually thereafter, each
health insurer subject to this section shall submit a report to
the office of the total number of claims submitted for orthoses
and prostheses services in the previous plan year and the total
number of such claims that were paid, including the amount paid.
       Section 5. Section 641.31079, Florida Statutes, is created
to read:
       641.31079 Orthotics and prosthetics services.—
       (1) A health maintenance contract issued, amended,
delivered, or renewed in this state on or after July 1, 2024,
must provide coverage for all of the following:
       (a) Orthoses and prostheses as those terms are defined in
s. 468.80 if the subscriber’s provider determines that an
orthosis or a prosthesis is medically necessary for the
subscriber to perform activities of daily living, essential job
related activities, and physical recreational activities, such
as running, biking, swimming, strength training, and other
activities that maximize the subscriber’s full body health and
lower and upper limb function.
       (b) Any replacement of the orthosis or prosthesis, or part
thereof, without regard to continuous use or useful lifetime
restrictions, if the subscriber’s provider determines that it is
medically necessary due to any of the following:
       1. A change in the physiological condition of the
subscriber.
       2. An irreparable change in the condition of the orthosis
or prosthesis, or part thereof.
       3. The condition of the device, or part thereof, requires
repairs and the cost of the repairs would be more than 60
percent of the cost of a replacement orthosis or prosthesis or
of the part thereof requiring replacement.

A health maintenance organization may require supporting
documentation from a subscriber’s provider to confirm the need
for a replacement for an orthosis or a prosthesis that is less
than 3 years old.
       (2) A health maintenance organization may not deny a claim
for an orthosis or a prosthesis for a subscriber with limb loss
or limb absence which would otherwise be covered for a
nondisabled person seeking medical or surgical intervention to
restore or maintain the ability to perform the same type of
physical function affected.
       (3) Beginning July 1, 2025, and annually thereafter, each
health maintenance organization subject to this section shall
submit a report to the office of the total number of claims
submitted for orthoses and prostheses services in the previous
plan year and the total number of such claims that were paid,
including the amount paid.
       Section 6. This act shall take effect July 1, 2024.
Statutes affected: 
S 828 Filed: 409.906