This bill introduces a new section to chapter 48.43 RCW, mandating that health plans in the large and small group markets provide coverage for prosthetic limbs and custom orthotic braces when deemed medically necessary. Effective January 1, 2026, the coverage must include one or more prostheses and braces per limb, as well as necessary materials, components, related services, and instruction for use. Additionally, the bill stipulates that coverage for repairs or replacements of these devices cannot be denied based on continuous use or useful lifetime restrictions if medically necessary due to changes in the patient's condition or the device's condition.

The legislation also prohibits health plans from denying coverage for prosthetic limbs or custom orthotic braces to enrollees with disabilities if similar services would be covered for nondisabled individuals. Health plans may apply standard utilization management practices, but any denial of coverage must be documented in writing. Furthermore, the bill requires health plans to report claims data related to these services to the insurance commissioner by July 1, 2028, and ensures that payment for these services aligns with federal regulations for aged and disabled individuals. Notably, the provisions do not apply to health plans in the individual market or to certain public employee health plans.