F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
HB 1003 2024
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, subject to specific
7 appropriations; requiring the agency to seek federal
8 approval, if necessary, and amend contracts as
9 necessary to implement the services payment
10 provisions; creating ss. 627.64085, 627.6614, and
11 641.31079, F.S.; requiring individual health insurance
12 policies, group, blanket, and franchise health
13 insurance policies, and health maintenance contracts,
14 respectively, to provide coverage for specified
15 orthotics and prosthetics services; prohibiting health
16 insurers and health maintenance organizations from
17 denying claims under certain circumstances; requiring
18 health insurers and health maintenance organizations
19 to submit annual reports of specified information to
20 the Office of Insurance Regulation; providing an
21 effective date.
22
23 Be It Enacted by the Legislature of the State of Florida:
24
25 Section 1. Subsection (10) of section 409.906, Florida
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26 Statutes, is amended to read:
27 409.906 Optional Medicaid services.—Subject to specific
28 appropriations, the agency may make payments for services which
29 are optional to the state under Title XIX of the Social Security
30 Act and are furnished by Medicaid providers to recipients who
31 are determined to be eligible on the dates on which the services
32 were provided. Any optional service that is provided shall be
33 provided only when medically necessary and in accordance with
34 state and federal law. Optional services rendered by providers
35 in mobile units to Medicaid recipients may be restricted or
36 prohibited by the agency. Nothing in this section shall be
37 construed to prevent or limit the agency from adjusting fees,
38 reimbursement rates, lengths of stay, number of visits, or
39 number of services, or making any other adjustments necessary to
40 comply with the availability of moneys and any limitations or
41 directions provided for in the General Appropriations Act or
42 chapter 216. If necessary to safeguard the state's systems of
43 providing services to elderly and disabled persons and subject
44 to the notice and review provisions of s. 216.177, the Governor
45 may direct the Agency for Health Care Administration to amend
46 the Medicaid state plan to delete the optional Medicaid service
47 known as "Intermediate Care Facilities for the Developmentally
48 Disabled." Optional services may include:
49 (10) DURABLE MEDICAL EQUIPMENT.—
50 (a) The agency may authorize and pay for certain durable
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51 medical equipment and supplies provided to a Medicaid recipient
52 as medically necessary.
53 (b) The agency may authorize and pay for all of the
54 following orthotics and prosthetics services:
55 1. Orthoses and prostheses as those terms are defined in
56 s. 468.80. Coverage must include payment for the model of an
57 orthosis or prosthesis which is deemed by the recipient's
58 provider to be the most appropriate to meet the medical needs of
59 the recipient to perform activities of daily living, essential
60 job-related activities, and physical recreational activities
61 that maximize the recipient's full body health and lower and
62 upper limb function.
63 2. All materials and components necessary to use the
64 orthosis or prosthesis.
65 3. Instruction on the use of the orthosis or prosthesis.
66 4. Any necessary repairs or replacement of the orthosis or
67 prosthesis.
68 Section 2. The Agency for Health Care Administration shall
69 seek federal approval, if necessary, and amend contracts as
70 necessary to implement the changes made to s. 409.906, Florida
71 Statutes, by this act.
72 Section 3. Section 627.64085, Florida Statutes, is created
73 to read:
74 627.64085 Orthotics and prosthetics services.—
75 (1) A health insurance policy issued, amended, delivered,
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76 or renewed in this state on or after July 1, 2024, must provide
77 coverage for all of the following:
78 (a) Orthoses and prostheses as those terms are defined in
79 s. 468.80 if the insured's provider determines that an orthosis
80 or prosthesis is medically necessary for the insured to perform
81 activities of daily living, essential job-related activities,
82 and physical recreational activities, such as running, biking,
83 swimming, strength training, and other activities that maximize
84 the insured's full body health and lower and upper limb
85 function.
86 (b) Any replacement of the orthosis or prosthesis, or part
87 thereof, without regard to continuous use or useful lifetime
88 restrictions, if the insured's provider determines that it is
89 medically necessary due to any of the following:
90 1. A change in the physiological condition of the insured.
91 2. An irreparable change in the condition of the orthosis
92 or prosthesis, or part thereof.
93 3. The condition of the device, or part thereof, requires
94 repairs and the cost of the repairs would be more than 60
95 percent of the cost of a replacement orthosis or prosthesis or
96 of the part thereof requiring replacement.
97
98 A health insurer may require supporting documentation fr om an
99 insured's provider to confirm the need for a replacement for an
100 orthosis or a prosthesis that is less than 3 years old.
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101 (2) A health insurer may not deny a claim for an orthosis
102 or a prosthesis for an insured with limb loss or limb absence
103 which would otherwise be covered for a nondisabled person
104 seeking medical or surgical intervention to restore or maintain
105 the ability to perform the same type of physical function
106 affected.
107 (3) Beginning July 1, 2025, and annually thereafter, each
108 health insurer subject to this section shall submit a report to
109 the office of the total number of claims submitted for orthoses
110 and prostheses services in the previous plan year and the total
111 number of such claims that were paid, including the amount paid.
112 Section 4. Section 627.6614, Florida Statutes, is created
113 to read:
114 627.6614 Orthotics and prosthetics services.—
115 (1) A group, blanket, or franchise health insurance policy
116 issued, amended, delivered, or renewed in this state on or after
117 July 1, 2024, must provide coverage for all of the following:
118 (a) Orthoses and prostheses as those terms are defined in
119 s. 468.80 if the insured's provider determines that an orthosis
120 or prosthesis is medically necessary for the insured to perform
121 activities of daily living, essential job-related activities,
122 and physical recreational activities, such as running, biking,
123 swimming, strength training, and other activities that maximize
124 the insured's full body health and lower and upper limb
125 function.
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126 (b) Any replacement of the orthosis or prosthesis, or part
127 thereof, without regard to continuous use or useful lifetime
128 restrictions, if the insured's provider determines that it is
129 medically necessary due to any of the following:
130 1. A change in the physiological condition of the in sured.
131 2. An irreparable change in the condition of the orthosis
132 or prosthesis, or part thereof.
133 3. The condition of the device, or part thereof, requires
134 repairs and the cost of the repairs would be more than 60
135 percent of the cost of a replacement orthosis or prosthesis or
136 of the part thereof requiring replacement.
137
138 A health insurer may require supporting documentation from an
139 insured's provider to confirm the need for a replacement for an
140 orthosis or a prosthesis that is less than 3 years old.
141 (2) A health insurer may not deny a claim for an orthosis
142 or a prosthesis for an insured with limb loss or limb absence
143 which would otherwise be covered for a nondisabled person
144 seeking medical or surgical intervention to restore or maintain
145 the ability to perform the same type of physical function
146 affected.
147 (3) Beginning July 1, 2025, and annually thereafter, each
148 health insurer subject to this section shall submit a report to
149 the office of the total number of claims submitted for orthoses
150 and prostheses services in the previous plan year and the total
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151 number of such claims that were paid, including the amount paid.
152 Section 5. Section 641.31079, Florida Statutes, is created
153 to read:
154 641.31079 Orthotics and prosthetics services.—
155 (1) A health maintenance contract issued, amended,
156 delivered, or renewed in this state on or after July 1, 2024,
157 must provide coverage for all of the following:
158 (a) Orthoses and prostheses as those terms are defined in
159 s. 468.80 if the subscriber's provider determines that an
160 orthosis or prosthesis is medically necessary for the subscriber
161 to perform activities of daily living, essential job-related
162 activities, and physical recreational activities, such as
163 running, biking, swimming, strength training, and other
164 activities that maximize the subscriber's full body health and
165 lower and upper limb function.
166 (b) Any replacement of the orthosis or prosthesis, or part
167 thereof, without regard to continuous use or useful lifetime
168 restrictions, if the subscriber's provider determines t hat it is
169 medically necessary due to any of the following:
170 1. A change in the physiological condition of the
171 subscriber.
172 2. An irreparable change in the condition of the orthosis
173 or prosthesis, or part thereof.
174 3. The condition of the device, or part thereof, requires
175 repairs and the cost of the repairs would be more than 60
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176 percent of the cost of a replacement orthosis or prosthesis or
177 of the part thereof requiring replacement.
178
179 A health maintenance organization may require supporting
180 documentation from a subscriber's provider to confirm the need
181 for a replacement for an orthosis or a prosthesis that is less
182 than 3 years old.
183 (2) A health maintenance organization may not deny a claim
184 for an orthosis or a prosthesis for a subscriber with limb loss
185 or limb absence which would otherwise be covered for a
186 nondisabled person seeking medical or surgical intervention to
187 restore or maintain the ability to perform the same type of
188 physical function affected.
189 (3) Beginning July 1, 2025, and annually thereafter, each
190 health maintenance organization subject to this section shall
191 submit a report to the office of the total number of claims
192 submitted for orthoses and prostheses services in the previous
193 plan year and the total number of such claims that were paid,
194 including the amount paid.
195 Section 6. This act shall take effect July 1, 2024.
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