A 11406: Requires health insurance coverage for prosthetic and orthotic devices at a rate no less than the current quarter's Medicare durable medical equipment, prosthetics, orthotics and supplies fee schedule established by the Centers for Medicare and Medicaid services for prosthetic and orthotic devices and services.

  
  STATE OF NEW YORK ________________________________________________________________________ 11406  IN ASSEMBLY May 15, 2026 ___________ Introduced by COMMITTEE ON RULES -- (at request of M. of A. Ramos) -- read once and referred to the Committee on Insurance AN ACT to amend the insurance law, the social services law and the public health law, in relation to requiring certain health insurance coverage for prostheses and custom orthoses The People of the State of New York, represented in Senate and Assem- bly, do enact as follows: 1 Section 1. Subsection (i) of section 3216 of the insurance law is 2 amended by adding a new paragraph 42 to read as follows: 3 (42) (A) Every policy that provides coverage for hospital, medical or 4 surgical expenses shall include coverage for prosthetic and orthotic 5 devices that equals the coverage and payment provided for by federal 6 laws and regulations for the aged and disabled pursuant to 42 U.S.C., 7 sections 1395k, 1395l and 1395m and 42 C.F.R., sections 414.202, 8 414.210, 414.228 and 410.100, and any successor regulations, including 9 payment at a rate no less than the current quarter's medicare durable 10 medical equipment, prosthetics, orthotics and supplies fee schedule 11 established by the centers for medicare and medicaid services for pros- 12 thetic and orthotic devices and services. 13 (B) Coverage provided under this paragraph shall include: 14 (i) a prosthetic or orthotic device determined by the enrollee's 15 health care provider to be the most appropriate model that adequately 16 meets the medical needs of such enrollee; 17 (ii) a prosthetic or custom orthotic device determined by the 18 enrollee's health care provider to be the most appropriate model that 19 meets the medical needs of such enrollee for purposes of performing 20 physical activities, including, but not limited to, running, biking, 21 swimming, strength training, and to maximize such enrollee's whole-body 22 health and lower and/or upper limb function; 23 (iii) a prosthetic or custom orthotic device determined by the 24 enrollee's health care provider to be the most appropriate model that 25 meets the medical needs of such enrollee for purposes of showering or 26 bathing; EXPLANATION--Matter in italics (underscored) is new; matter in brackets [ ] is old law to be omitted. LBD15475-02-6 
 A. 11406 2 1 (iv) all materials and components necessary for the use of the 2 prostheses and orthoses; 3 (v) instruction to the enrollee on using the device; and 4 (vi) with respect to the prostheses and orthoses covered under items 5 (i), (ii), and (iii) of this subparagraph, the medically necessary 6 repair or replacement of such prosthetic or orthotic device. 7 (C) For an enrollee to receive a prosthesis or orthosis under items 8 (i), (ii), and (iii) of subparagraph (B) of this paragraph, the treating 9 health care provider shall be required to determine whether the addi- 10 tional prosthetic or custom orthotic device is necessary to enable such 11 enrollee to engage in physical activities, as applicable, including, but 12 not limited to, running, biking, swimming, strength training, showering, 13 bathing, and to maximize enrollee's whole-body health and lower and/or 14 upper limb function. 15 (D) Every policy that is delivered, issued for delivery or renewed in 16 this state that provides coverage for prosthetic and custom orthotic 17 devices shall consider such devices habilitative or rehabilitative bene- 18 fits for the purposes of any state or federal requirement for coverage 19 of essential health benefits. 20 (E) An insurer shall not deny a prosthetic or orthotic benefit for an 21 individual with limb loss or absence that would otherwise be covered for 22 a non-disabled individual seeking medical or surgical intervention to 23 restore or maintain the ability to perform the same physical activity. 24 (F) Prosthetic and custom orthotic device coverage shall not be 25 subject to separate financial requirements that are applicable only with 26 respect to that coverage. Cost-sharing may be imposed on prosthetic or 27 custom orthotic devices; provided, however, that any cost-sharing 28 requirements shall not be more restrictive than the cost-sharing 29 requirements applicable to coverage for inpatient physician and surgical 30 services. 31 (G) (i) If coverage for prosthetic or custom orthotic devices is 32 provided, payment shall be made for the replacement of such prosthetic 33 or custom orthotic device or for the replacement of any part of such 34 devices, without regard to continuous use or useful lifetime 35 restrictions, if an ordering health care provider determines that the 36 provision of a replacement device, or a replacement part of such a 37 device, is necessary because of any of the following: 38 (1) a change in the physiological condition of the enrollee; 39 (2) an irreparable change in the condition of the device or in a part 40 of such device; or 41 (3) the condition of the device, or the part of the device requires 42 repairs and the cost of such repairs would be more than sixty percent of 43 the cost of a replacement device or of the part being replaced. 44 (ii) Confirmation from a prescribing health care provider may be 45 required if the prosthetic or custom orthotic device or part being 46 replaced is less than three years old. 47 § 2. Subsection (l) of section 3221 of the insurance law is amended by 48 adding a new paragraph 24 to read as follows: 49 (24) (A) Every group or blanket policy delivered or issued for deliv- 50 ery in this state that provides coverage for hospital, medical or surgi- 51 cal expenses shall include coverage for prosthetic and orthotic devices 52 that equals the coverage and payment provided for by federal laws and 53 regulations for the aged and disabled pursuant to 42 U.S.C., sections 54 1395k, 1395l and 1395m and 42 C.F.R., sections 414.202, 414.210, 414.228 55 and 410.100, and any successor regulations, including payment at a rate 56 no less than the current quarter's medicare durable medical equipment, 
 A. 11406 3 1 prosthetics, orthotics and supplies fee schedule established by the 2 centers for medicare and medicaid services for prosthetic and orthotic 3 devices and services. 4 (B) Coverage provided under this paragraph shall include: 5 (i) a prosthetic or orthotic device determined by the enrollee's 6 health care provider to be the most appropriate model that adequately 7 meets the medical needs of such enrollee; 8 (ii) a prosthetic or custom orthotic device determined by the 9 enrollee's health care provider to be the most appropriate model that 10 meets the medical needs of such enrollee for purposes of performing 11 physical activities, including, but not limited to, running, biking, 12 swimming, strength training, and to maximize such enrollee's whole-body 13 health and lower and/or upper limb function; 14 (iii) a prosthetic or custom orthotic device determined by the 15 enrollee's health care provider to be the most appropriate model that 16 meets the medical needs of such enrollee for purposes of showering or 17 bathing; 18 (iv) all materials and components necessary for the use of the 19 prostheses and orthoses; 20 (v) instruction to the enrollee on using the device; and 21 (vi) with respect to the prostheses and orthoses covered under items 22 (i), (ii), and (iii) of this subparagraph, the medically necessary 23 repair or replacement of such prosthetic or orthotic device. 24 (C) For an enrollee to receive a prosthesis or orthosis under items 25 (i), (ii), and (iii) of subparagraph (B) of this paragraph, the treating 26 health care provider shall be required to determine whether the addi- 27 tional prosthetic or custom orthotic device is necessary to enable such 28 enrollee to engage in physical activities, as applicable, including, but 29 not limited to, running, biking, swimming, strength training, showering, 30 bathing, and to maximize enrollee's whole-body health and lower and/or 31 upper limb function. 32 (D) Every group or blanket policy delivered, issued for delivery or 33 renewed in this state that provides coverage for prosthetic and custom 34 orthotic devices shall consider such devices habilitative or rehabilita- 35 tive benefits for the purposes of any state or federal requirement for 36 coverage of essential health benefits. 37 (E) An insurer shall not deny a prosthetic or orthotic benefit for an 38 individual with limb loss or absence that would otherwise be covered for 39 a non-disabled individual seeking medical or surgical intervention to 40 restore or maintain the ability to perform the same physical activity. 41 (F) Prosthetic and custom orthotic device coverage shall not be 42 subject to separate financial requirements that are applicable only with 43 respect to that coverage. Cost-sharing may be imposed on prosthetic or 44 custom orthotic devices; provided, however, that any cost-sharing 45 requirements shall not be more restrictive than the cost-sharing 46 requirements applicable to coverage for inpatient physician and surgical 47 services. 48 (G) (i) If coverage for prosthetic or custom orthotic devices is 49 provided, payment shall be made for the replacement of such prosthetic 50 or custom orthotic device or for the replacement of any part of such 51 devices, without regard to continuous use or useful lifetime 52 restrictions, if an ordering health care provider determines that the 53 provision of a replacement device, or a replacement part of such a 54 device, is necessary because of any of the following: 55 (1) a change in the physiological condition of the enrollee; 
 A. 11406 4 1 (2) an irreparable change in the condition of the device or in a part 2 of such device; or 3 (3) the condition of the device, or the part of the device requires 4 repairs and the cost of such repairs would be more than sixty percent of 5 the cost of a replacement device or of the part being replaced. 6 (ii) Confirmation from a prescribing health care provider may be 7 required if the prosthetic or custom orthotic device or part being 8 replaced is less than three years old. 9 § 3. Section 4303 of the insurance law is amended by adding a new 10 subsection (yy) to read as follows: 11 (yy) (1) Every policy that provides coverage for hospital, medical or 12 surgical expenses shall include coverage for prosthetic and orthotic 13 devices that equals the coverage and payment provided for by federal 14 laws and regulations for the aged and disabled pursuant to 42 U.S.C., 15 sections 1395k, 1395l and 1395m and 42 C.F.R., sections 414.202, 16 414.210, 414.228 and 410.100, and any successor regulations, including 17 payment at a rate no less than the current quarter's medicare durable 18 medical equipment, prosthetics, orthotics and supplies fee schedule 19 established by the centers for medicare and medicaid services for pros- 20 thetic and orthotic devices and services. 21 (2) Coverage provided under this subsection shall include: 22 (A) a prosthetic or orthotic device determined by the enrollee's 23 health care provider to be the most appropriate model that adequately 24 meets the medical needs of such enrollee; 25 (B) a prosthetic or custom orthotic device determined by the 26 enrollee's health care provider to be the most appropriate model that 27 meets the medical needs of such enrollee for purposes of performing 28 physical activities, including, but not limited to, running, biking, 29 swimming, strength training, and to maximize such enrollee's whole-body 30 health and lower and/or upper limb function; 31 (C) a prosthetic or custom orthotic device determined by the 32 enrollee's health care provider to be the most appropriate model that 33 meets the medical needs of such enrollee for purposes of showering or 34 bathing; 35 (D) all materials and components necessary for the use of the 36 prostheses and orthoses; 37 (E) instruction to the enrollee on using the device; and 38 (F) with respect to the prostheses and orthoses covered under subpara- 39 graphs (A), (B), and (C) of this paragraph, the medically necessary 40 repair or replacement of such prosthetic or orthotic device. 41 (3) For an enrollee to receive a prosthesis or orthosis under subpara- 42 graphs (A), (B), and (C) of paragraph two of this subsection, the treat- 43 ing health care provider shall be required to determine whether the 44 additional prosthetic or custom orthotic device is necessary to enable 45 such enrollee to engage in physical activities, as applicable, includ- 46 ing, but not limited to, running, biking, swimming, strength training, 47 showering, bathing, and to maximize enrollee's whole-body health and 48 lower and/or upper limb function. 49 (4) Every policy delivered, issued for delivery or renewed in this 50 state that provides coverage for prosthetic and custom orthotic devices 51 shall consider such devices habilitative or rehabilitative benefits for 52 the purposes of any state or federal requirement for coverage of essen- 53 tial health benefits. 54 (5) An insurer shall not deny a prosthetic or orthotic benefit for an 55 individual with limb loss or absence that would otherwise be covered for 
 A. 11406 5 1 a non-disabled individual seeking medical or surgical intervention to 2 restore or maintain the ability to perform the same physical activity. 3 (6) Prosthetic and custom orthotic device coverage shall not be 4 subject to separate financial requirements that are applicable only with 5 respect to that coverage. Cost-sharing may be imposed on prosthetic or 6 custom orthotic devices; provided, however, that any cost-sharing 7 requirements shall not be more restrictive than the cost-sharing 8 requirements applicable to coverage for inpatient physician and surgical 9 services. 10 (7) (A) If coverage for prosthetic or custom orthotic devices is 11 provided, payment shall be made for the replacement of such prosthetic 12 or custom orthotic device or for the replacement of any part of such 13 devices, without regard to continuous use or useful lifetime 14 restrictions, if an ordering health care provider determines that the 15 provision of a replacement device, or a replacement part of such a 16 device, is necessary because of any of the following: 17 (i) a change in the physiological condition of the enrollee; 18 (ii) an irreparable change in the condition of the device or in a part 19 of such device; or 20 (iii) the condition of the device, or the part of the device requires 21 repairs and the cost of such repairs would be more than sixty percent of 22 the cost of a replacement device or of the part being replaced. 23 (B) Confirmation from a prescribing health care provider may be 24 required if the prosthetic or custom orthotic device or part being 25 replaced is less than three years old. 26 § 4. Subdivision 4 of section 364-j of the social services law is 27 amended by adding a new paragraph (x) to read as follows: 28 (x) A managed care provider shall provide or arrange, directly or 29 indirectly, including by referral, for access to and coverage of 30 services for the provision of prosthetic and orthotic devices to ensure 31 access to medically necessary clinical care. Such access shall include, 32 but not be limited to, prosthetic and custom orthotic devices and tech- 33 nology from no less than two distinct prosthetic and custom orthotic 34 providers within the managed care provider's network. In the event that 35 medically necessary covered prosthetics and orthotics are not available 36 from an in-network provider, such managed care provider shall establish 37 and maintain processes to refer a participant to an out-of-network 38 provider and shall fully reimburse such out-of-network provider at a 39 mutually agreed upon rate reduced by any participant cost-sharing deter- 40 mined on an in-network basis. 41 § 5. Subsection (a) of section 4902 of the insurance law is amended by 42 adding a new paragraph 17 to read as follows: 43 (17) When conducting utilization review for the purposes of determin- 44 ing health care coverage for prosthetic and orthotic devices, a utiliza- 45 tion review agent shall conduct such review in a nondiscriminatory 46 manner and not deny coverage for habilitative or rehabilitative bene- 47 fits, including prosthetics or orthotics, solely on the basis of an 48 insured's actual or perceived disability. 49 § 6. The public health law is amended by adding a new section 4406-j 50 to read as follows: 51 § 4406-j. Prosthetic and orthotic device coverage. No health mainte- 52 nance organization subject to this article shall, by contract, written 53 policy, or procedure, limit a patient enrollee's access to and coverage 54 of services for the provision of prosthetic and orthotic devices if such 55 services are covered pursuant to paragraph forty-two of subsection (i) 56 of section three thousand two hundred sixteen of the insurance law, 
 A. 11406 6 1 paragraph twenty-four of subsection (l) of section three thousand two 2 hundred twenty-one of the insurance law, or subsection (yy) of section 3 four thousand three hundred three of the insurance law; provided, howev- 4 er, that such patient enrollee's access to such services are otherwise 5 subject to the terms and conditions of the plan under which such patient 6 enrollee is covered. 7 § 7. Section 345 of the insurance law, as added by section 12 of part 8 YY of chapter 56 of the laws of 2020, is amended to read as follows: 9 § 345. Health care claims reports. An insurer authorized to write 10 accident and health insurance in the state, a corporation organized 11 pursuant to article forty-three of this chapter, or a health maintenance 12 organization certified pursuant to article forty-four of the public 13 health law shall report to the superintendent quarterly and annually on 14 health care claims payment performance with respect to comprehensive 15 health insurance coverage. The reports shall be submitted in the manner 16 and form prescribed by the superintendent after consultation with repre- 17 sentatives of insurers and health care providers but at minimum shall 18 include the number and dollar value of health care claims by major line 19 of business and categorized as follows: health care claims received, 20 health care claims paid, health care claims pended and health care 21 claims denied during the respective quarter or year. Such reports shall 22 also include the number of claims filed and the total amount of claims 23 paid in the state of New York for the services required by paragraph 24 forty-two of subsection (i) of section three thousand two hundred 25 sixteen of this chapter, paragraph twenty-four of subsection (l) of 26 section three thousand two hundred twenty-one of this chapter, 27 subsection (yy) of section four thousand three hundred three of this 28 chapter, or section forty-four hundred six-j of the public health law. 29 The data shall be provided in the aggregate and by major category of 30 health care provider. The reports should address any patterns or 31 suspected areas of revenue maximization that may have contributed to the 32 number of denials. The reports shall be due to the superintendent no 33 later than forty-five days after the end of the respective quarter or 34 year and shall be made publicly available including on the department's 35 website. The superintendent, in conjunction with the commissioner of 36 health, may promulgate regulations requiring additional reporting 37 requirements on insurers, corporations, or health maintenance organiza- 38 tions or health care providers to assess the effectiveness of the 39 payment policies set forth in this section, which may be informed by the 40 administrative simplification workgroup authorized by subsection (k) of 41 section three thousand two hundred twenty-four-a of this chapter. 42 § 8. This act shall take effect January 1, 2027 and shall apply to all 43 policies and contracts issued, renewed, modified, altered or amended on 44 or after such date; provided, however, that the amendments to section 45 364-j of the social services law made by section four of this act, shall 46 not affect the repeal of such section and shall be deemed repealed ther- 47 ewith. Effective immediately, the addition, amendment and/or repeal of 48 any rule or regulation necessary for the implementation of this act on 49 its effective date are authorized to be made and completed on or before 50 such effective date.