Requires certain health insurance coverage for prostheses and custom orthoses
This bill would require most New York health insurance policies, group and blanket policies, and health maintenance organizations to cover prosthetic and orthotic devices at no less than the current Medicare DMEPOS fee schedule. It expands coverage to include not only a basic medically necessary prosthesis or orthosis, but also additional devices determined by a health care provider to be appropriate for physical activities, showering or bathing, and to maximize whole-body health and limb function. Covered benefits would also include necessary materials, components, instruction on use, and medically necessary repair or replacement.
The bill also prohibits insurers from denying prosthetic or orthotic benefits to a person with limb loss or absence when the same type of service would be covered for a non-disabled person seeking to restore or maintain the same physical activity. It limits cost-sharing by barring special financial requirements targeted only at prosthetic/orthotic coverage and caps cost-sharing at no more restrictive a level than inpatient physician and surgical services. Replacement coverage would be required without ordinary useful-lifetime or continuous-use restrictions when a provider determines replacement is medically necessary, subject to limited confirmation for items less than three years old.
The bill would amend the Insurance Law, Social Services Law, and Public Health Law to create a statewide coverage mandate for prosthetic and custom orthotic devices across individual, group, blanket, and HMO coverage, and to require managed care access to at least two in-network prosthetic/orthotic providers or out-of-network referral and reimbursement when needed. It also adds nondiscrimination standards for utilization review and requires insurers to report claims data related to these services, including denials and payment amounts, in publicly available quarterly and annual reports. The measure would apply to policies and contracts issued, renewed, modified, altered, or amended on or after January 1, 2027.
The bill’s overall posture appears supportive of expanded access to prosthetic and orthotic care, with the text emphasizing medical necessity, functional restoration, and parity with coverage available to non-disabled individuals. Because there are no recorded votes or committee transcript excerpts in the provided materials, there is no documented floor or committee debate to indicate formal opposition or support beyond the bill’s introduction and amendment process. The available context suggests the bill was advanced in committee and remains under Assembly Committee consideration.
The main likely points of contention are cost and utilization controls. Insurers may object to the requirement to cover higher-cost or additional devices, to the prohibition on restrictive cost-sharing, to the removal of lifetime and continuous-use replacement limits, and to the requirement to reimburse out-of-network providers when in-network options are unavailable. Another possible issue is the bill’s broad definition of covered devices and activities, including athletic use and bathing/showering devices, which could be viewed as expanding coverage beyond traditional functional prosthetic needs. Advocates for amputees and disability access would likely support these provisions as necessary to prevent discriminatory coverage limits and to improve mobility, independence, and quality of life.