SB 72

                                                             Introduced Version
             SENATE BILL No. 72
                  _____
               DIGEST OF INTRODUCED BILL
Citations Affected: IC 5-10-8-14; IC 27-1-3-35.5; IC 27-8-24.2;
IC 27-13-7-19.
Synopsis: Coverage of orthotic and prosthetic devices. Sets forth
requirements for coverage of orthotic devices and prosthetic devices by
a state employee health plan, a policy of accident and sickness
insurance, and a health maintenance organization contract. Requires,
not later than October 1, 2027, the state personnel department, an
insurer that issues a policy of accident and sickness insurance, and a
health maintenance organization to submit a report to the insurance
commissioner regarding the total number of claims and the total
amount of claims paid for orthotic devices and prosthetic devices
during the preceding plan year. Requires the insurance commissioner
to: (1) aggregate the data received in the reports regarding coverage of
orthotic devices and prosthetic devices; and (2) report the aggregated
data, not later than December 1, 2027, to the standing committees of
the house of representatives and the senate that consider insurance
matters. Makes corresponding changes.
Effective: July 1, 2026.
                                Hunley
 December 8, 2025, read first time and referred to Committee on Insurance and Financial
Institutions.
2026  IN 72—LS 6216/DI 141
                                                                                       Introduced
            Second Regular Session of the 124th General Assembly (2026)
 PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
 Constitution) is being amended, the text of the existing provision will appear in this style type,
 additions will appear in this style type, and deletions will appear in this style type.
   Additions: Whenever a new statutory provision is being enacted (or a new constitutional
 provision adopted), the text of the new provision will appear in this style type. Also, the
 word NEW will appear in that style type in the introductory clause of each SECTION that adds
 a new provision to the Indiana Code or the Indiana Constitution.
  Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
 between statutes enacted by the 2025 Regular Session of the General Assembly.
                    SENATE BILL No. 72
    A BILL FOR AN ACT to amend the Indiana Code concerning
 insurance.
     Be it enacted by the General Assembly of the State of Indiana:
1     SECTION 1. IC 5-10-8-14, AS ADDED BY P.L.109-2008,
2 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
3 JULY 1, 2026]: Sec. 14. (a) This section applies to a state employee
4 health plan that is established, entered into, amended, or renewed
5 after June 30, 2026.
6     (a) (b) As used in this section, "covered individual" means an
7 individual who is entitled to coverage under a state employee health
8 plan.
9     (b) (c) As used in this section, "orthotic device" means a medically
10 necessary custom fabricated brace or support that is designed as a
11 component of a prosthetic device.
12     (c) (d) As used in this section, "prosthetic device" means an
13 artificial leg or arm.
14     (d) (e) As used in this section, "state employee health plan" means
15 a:
16(1) self-insurance program established under section 7(b) of this
17chapter; or
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                                      2
1(2) contract with a prepaid health care delivery plan that is
2entered into or renewed under section 7(c) of this chapter;
3 to provide group health coverage. The term does not include a dental
4 or vision plan.
5    (e) (f) A state employee health plan must provide coverage for the
6 following:
7(1) An orthotic devices and device or a prosthetic devices,
8including repairs or replacements, device that is determined by
9the covered individual's provider to be the most appropriate
10model that adequately meets the medical needs of the covered
11individual.
12(1) are provided or performed by a person that is:
13(A) accredited as required under 42 U.S.C. 1395m(a)(20); or
14(B) a qualified practitioner (as defined in 42 U.S.C.
151395m(h)(1)(F)(iii));
16(2) are An orthotic device or a prosthetic device that is
17determined by the covered individual's physician provider to be
18medically necessary to restore or maintain the covered
19individual's ability to perform activities of daily living or essential
20job related activities; and the most appropriate model that
21meets the medical needs of the covered individual for
22purposes of:
23(A) performing physical activities, as applicable, such as
24running, biking, swimming, and strength training; and
25(B) maximizing the covered individual's whole body health
26and lower or upper limb function.
27(3) are not solely for comfort or convenience. An orthotic device
28or a prosthetic device that is determined by the covered
29individual's provider to be the most appropriate model that
30meets the medical needs of the covered individual for
31purposes of showering or bathing.
32(4) All materials and components necessary to use the orthotic
33devices and prosthetic devices described in subdivisions (1)
34through (3).
35(5) Instruction to the covered individual on using the orthotic
36devices and prosthetic devices described in subdivisions (1)
37through (3).
38(6) The medically necessary repair or replacement of the
39orthotic devices and prosthetic devices described in
40subdivisions (1) through (3).
41    (g) With respect to a covered individual who receives an
42 orthotic device or a prosthetic device under subsection (f)(1),
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                                    3
1 coverage of an additional orthotic device or prosthetic device
2 under subsection (f)(2) or (f)(3) must require the covered
3 individual's treating physician to determine that the additional
4 orthotic device or prosthetic device under subsection (f)(2) or (f)(3)
5 is necessary to enable the covered individual to engage in the
6 activities described in subsection (f)(2) or (f)(3).
7    (f) (h) The:
8(1) coverage required under subsection (e) (f) must be equal to
9the coverage that is provided for the same device, repair, or
10replacement under the federal Medicare program (42 U.S.C. 1395
11et seq.) and the regulations under 42 CFR 410.100, 42 CFR
12414.202, 42 CFR 414.210, and 42 CFR 414.228; and
13(2) reimbursement under the coverage required under subsection
14(e) (f) must be equal to the reimbursement that is provided for the
15same device, repair, or replacement under the federal Medicare
16reimbursement schedule, unless a different reimbursement rate is
17negotiated.
18 This subsection does not require a deductible under a state employee
19 health plan to be equal to a deductible under the federal Medicare
20 program.
21    (g) (i) Except as provided in subsections (h) and (i), subsection (k),
22 the coverage required under subsection (e): (f):
23(1) may be subject to; and
24(2) may not be more restrictive than;
25 the provisions that apply to other benefits under the state employee
26 health plan.
27    (j) A state employee health plan shall consider the coverage
28 required under subsection (f) to be habilitative or rehabilitative
29 benefits for purposes of any state or federal requirement for
30 coverage of essential health benefits.
31    (h) (k) The coverage required under subsection (e) (f) may be
32 subject to utilization review, including periodic review, of the
33 continued medical necessity of the benefit. A state employee health
34 plan:
35(1) shall render utilization review determinations in a
36nondiscriminatory manner; and
37(2) may not deny coverage for habilitative or rehabilitative
38benefits, including orthotic devices or prosthetic devices,
39solely on the basis of a covered individual's actual or
40perceived disability.
41    (l) A state employee health plan may not deny coverage for an
42 orthotic device or a prosthetic device for a covered individual with
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                                   4
1 limb loss or absence that would otherwise be covered for a covered
2 individual without a disability who seeks medical or surgical
3 intervention to restore or maintain the ability to perform the same
4 physical activity.
5     (m) A state employee health plan shall include language
6 describing a covered individual's rights under subsections (k) and
7 (l) in the state employee health plan's evidence of coverage and any
8 denial letters.
9     (n) A state employee health plan shall ensure that covered
10 individuals have access to medically necessary clinical care and
11 orthotic devices and prosthetic devices from at least two (2) distinct
12 orthotic device and prosthetic device providers in the state
13 employee health plan's network. If medically necessary orthotic
14 devices and prosthetic devices are not available from an in network
15 provider, the state employee health plan shall:
16(1) provide processes to refer a covered individual to an out
17of network provider; and
18(2) fully reimburse the out of network provider at a mutually
19agreed upon rate reduced by the covered individual's cost
20sharing determined on an in network basis.
21     (o) If a state employee health plan provides coverage for an
22 orthotic device or prosthetic device, the state employee health plan
23 shall provide coverage for the replacement of the orthotic device,
24 the prosthetic device, or any part of the orthotic device or
25 prosthetic device without regard to continuous use or useful
26 lifetime restrictions if an ordering provider determines that the
27 replacement device or part is necessary because of any of the
28 following:
29(1) A change in the physiological condition of the covered
30individual.
31(2) An irreparable change in the condition of the device or
32part.
33(3) The condition of the device or part requires repairs and
34the cost of the repairs would be more than sixty percent
35(60%) of the cost of a replacement device or part.
36 The state employee health plan may require confirmation from a
37 prescribing provider if the device or part that is being replaced is
38 less than three (3) years old.
39     (i) Any lifetime maximum coverage limitation that applies to
40 prosthetic devices and orthotic devices:
41(1) must not be included in; and
42(2) must be equal to;
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1 the lifetime maximum coverage limitation that applies to all other items
2 and services generally under the state employee health plan.
3     (j) (p) For purposes of this subsection, "items and services" does not
4 include preventive services for which coverage is provided under a
5 high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26
6 U.S.C. 223(c)(2)). The coverage required under subsection (e) (f) may
7 not be subject to a deductible, copayment, or coinsurance provision that
8 is less favorable to a covered individual than the deductible,
9 copayment, or coinsurance provisions that apply to other items and
10 services generally under the state employee health plan.
11     (q) Not later than October 1, 2027, the state personnel
12 department shall submit a report to the insurance commissioner
13 regarding a state employee's health plan coverage of orthotic
14 devices and prosthetic devices. The report must:
15(1) be on a form prescribed by the insurance commissioner;
16and
17(2) include the total number of claims and the total amount of
18claims paid for the services required under subsection (f)
19during the preceding plan year.
20 This subsection expires June 30, 2028.
21     SECTION 2. IC 27-1-3-35.5 IS ADDED TO THE INDIANA CODE
22 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
23 1, 2026]: Sec. 35.5. (a) The commissioner shall aggregate the data
24 received under:
25(1) IC 5-10-8-14;
26(2) IC 27-8-24.2-11; and
27(3) IC 27-13-7-19.
28     (b) Not later than December 1, 2027, the commissioner shall
29 submit a report regarding the aggregated data under subsection (a)
30 in an electronic format under IC 5-14-6 to the standing committees
31 of the house of representatives and the senate that consider
32 insurance matters.
33     (c) This section expires June 30, 2028.
34     SECTION 3. IC 27-8-24.2-0.1, AS ADDED BY P.L.220-2011,
35 SECTION 450, IS AMENDED TO READ AS FOLLOWS
36 [EFFECTIVE JULY 1, 2026]: Sec. 0.1. The addition of This chapter by
37 P.L.109-2008 applies to a policy of accident and sickness insurance
38 that is issued, delivered, amended, or renewed after June 30, 2008.
39 2026.
40     SECTION 4. IC 27-8-24.2-5, AS ADDED BY P.L.109-2008,
41 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
42 JULY 1, 2026]: Sec. 5. A policy of accident and sickness insurance
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                                      6
1 must provide coverage for the following:
2      (1) An orthotic devices and device or a prosthetic devices,
3      including repairs or replacements, device that is determined by
4      the insured's provider to be the most appropriate model that
5      adequately meets the medical needs of the insured.
6      (1) are provided or performed by a person that is:
7(A) accredited as required under 42 U.S.C. 1395m(a)(20); or
8(B) a qualified practitioner (as defined in 42 U.S.C.
91395m(h)(1)(F)(iii));
10      (2) are An orthotic device or a prosthetic device that is
11      determined by the insured's physician provider to be medically
12      necessary to restore or maintain the insured's ability to perform
13      activities of daily living or essential job related activities; and the
14      most appropriate model that meets the medical needs of the
15      insured for purposes of:
16(A) performing physical activities, as applicable, such as
17running, biking, swimming, and strength training; and
18(B) maximizing the insured's whole body health and lower
19or upper limb function.
20      (3) are not solely for comfort or convenience. An orthotic device
21      or a prosthetic device that is determined by the insured's
22      provider to be the most appropriate model that meets the
23      medical needs of the insured for purposes of showering or
24      bathing.
25      (4) All materials and components necessary to use the orthotic
26      devices and prosthetic devices described in subdivisions (1)
27      through (3).
28      (5) Instruction to the insured on using the orthotic devices and
29      prosthetic devices described in subdivisions (1) through (3).
30      (6) The medically necessary repair or replacement of the
31      orthotic devices and prosthetic devices described in
32      subdivisions (1) through (3).
33     SECTION 5. IC 27-8-24.2-5.5 IS ADDED TO THE INDIANA
34 CODE AS A NEW SECTION TO READ AS FOLLOWS
35 [EFFECTIVE JULY 1, 2026]: Sec. 5.5. With respect to an insured
36 who receives an orthotic device or a prosthetic device under section
37 5(1) of this chapter, coverage of an additional orthotic device or
38 prosthetic device under section 5(2) or 5(3) of this chapter must
39 require the insured's treating physician to determine that the
40 additional orthotic device or prosthetic device under section 5(2)
41 or 5(3) of this chapter is necessary to enable the insured to engage
42 in the activities described in section 5(2) or 5(3) of this chapter.
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                                    7
1     SECTION 6. IC 27-8-24.2-6, AS ADDED BY P.L.109-2008,
2 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
3 JULY 1, 2026]: Sec. 6. The:
4(1) coverage required under section 5 of this chapter must be
5equal to the coverage that is provided for the same device, repair,
6or replacement under the federal Medicare program (42 U.S.C.
71395 et seq.) and the regulations under 42 CFR 410.100, 42
8CFR 414.202, 42 CFR 414.210, and 42 CFR 414.228; and
9(2) reimbursement under the coverage required under section 5 of
10this chapter must be equal to the reimbursement that is provided
11for the same device, repair, or replacement under the federal
12Medicare reimbursement schedule, unless a different
13reimbursement rate is negotiated.
14 This section does not require a deductible under a policy of accident
15 and sickness insurance to be equal to a deductible under the federal
16 Medicare program.
17     SECTION 7. IC 27-8-24.2-7, AS ADDED BY P.L.109-2008,
18 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
19 JULY 1, 2026]: Sec. 7. Except as provided in sections section 8 and 9
20 of this chapter, the coverage required under section 5 of this chapter:
21(1) may be subject to; and
22(2) may not be more restrictive than;
23 the provisions that apply to other benefits under the policy of accident
24 and sickness insurance.
25     SECTION 8. IC 27-8-24.2-7.5 IS ADDED TO THE INDIANA
26 CODE AS A NEW SECTION TO READ AS FOLLOWS
27 [EFFECTIVE JULY 1, 2026]: Sec. 7.5. A policy of accident and
28 sickness insurance shall consider the coverage required under
29 section 5 of this chapter to be habilitative or rehabilitative benefits
30 for purposes of any state or federal requirement for coverage of
31 essential health benefits.
32     SECTION 9. IC 27-8-24.2-8, AS ADDED BY P.L.109-2008,
33 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
34 JULY 1, 2026]: Sec. 8. (a) The coverage required under section 5 of
35 this chapter may be subject to utilization review, including periodic
36 review, of the continued medical necessity of the benefit.
37     (b) A policy of accident and sickness insurance:
38(1) shall render utilization review determinations in a
39nondiscriminatory manner; and
40(2) may not deny coverage for habilitative or rehabilitative
41benefits, including orthotic devices or prosthetic devices,
42solely on the basis of an insured's actual or perceived
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                                    8
1disability.
2    SECTION 10. IC 27-8-24.2-8.3 IS ADDED TO THE INDIANA
3 CODE AS A NEW SECTION TO READ AS FOLLOWS
4 [EFFECTIVE JULY 1, 2026]: Sec. 8.3. A policy of accident and
5 sickness insurance may not deny coverage for an orthotic device or
6 a prosthetic device for an insured with limb loss or absence that
7 would otherwise be covered for an insured without a disability who
8 seeks medical or surgical intervention to restore or maintain the
9 ability to perform the same physical activity.
10    SECTION 11. IC 27-8-24.2-8.5 IS ADDED TO THE INDIANA
11 CODE AS A NEW SECTION TO READ AS FOLLOWS
12 [EFFECTIVE JULY 1, 2026]: Sec. 8.5. A policy of accident and
13 sickness insurance shall include language describing an insured's
14 rights under sections 8 and 8.3 of this chapter in the policy of
15 accident and sickness insurance's evidence of coverage and any
16 denial letters.
17    SECTION 12. IC 27-8-24.2-8.7 IS ADDED TO THE INDIANA
18 CODE AS A NEW SECTION TO READ AS FOLLOWS
19 [EFFECTIVE JULY 1, 2026]: Sec. 8.7. A policy of accident and
20 sickness insurance shall ensure that insureds have access to
21 medically necessary clinical care and orthotic devices and
22 prosthetic devices from at least two (2) distinct orthotic device and
23 prosthetic device providers in the policy of accident and sickness
24 insurance's network. If medically necessary orthotic devices and
25 prosthetic devices are not available from an in network provider,
26 the policy of accident and sickness insurance shall:
27(1) provide processes to refer an insured to an out of network
28provider; and
29(2) fully reimburse the out of network provider at a mutually
30agreed upon rate reduced by the insured's cost sharing
31determined on an in network basis.
32    SECTION 13. IC 27-8-24.2-9 IS REPEALED [EFFECTIVE JULY
33 1, 2026]. Sec. 9. Any lifetime maximum coverage limitation that
34 applies to prosthetic devices and orthotic devices:
35(1) must not be included in; and
36(2) must be equal to;
37 the lifetime maximum coverage limitation that applies to all other items
38 and services generally under the policy of accident and sickness
39 insurance.
40    SECTION 14. IC 27-8-24.2-9.5 IS ADDED TO THE INDIANA
41 CODE AS A NEW SECTION TO READ AS FOLLOWS
42 [EFFECTIVE JULY 1, 2026]: Sec. 9.5. If a policy of accident and
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                                    9
1 sickness insurance provides coverage for an orthotic device or
2 prosthetic device, the policy of accident and sickness insurance
3 shall provide coverage for the replacement of the orthotic device,
4 the prosthetic device, or any part of the orthotic device or
5 prosthetic device without regard to continuous use or useful
6 lifetime restrictions if an ordering provider determines that the
7 replacement device or part is necessary because of any of the
8 following:
9(1) A change in the physiological condition of the insured.
10(2) An irreparable change in the condition of the device or
11part.
12(3) The condition of the device or part requires repairs and
13the cost of the repairs would be more than sixty percent
14(60%) of the cost of a replacement device or part.
15 The policy of accident and sickness insurance may require
16 confirmation from a prescribing provider if the device or part that
17 is being replaced is less than three (3) years old.
18     SECTION 15. IC 27-8-24.2-11 IS ADDED TO THE INDIANA
19 CODE AS A NEW SECTION TO READ AS FOLLOWS
20 [EFFECTIVE JULY 1, 2026]: Sec. 11. (a) Not later than October 1,
21 2027, an insurer that issues a policy of accident and sickness
22 insurance shall submit a report to the commissioner regarding the
23 policy of accident and sickness insurance's coverage of orthotic
24 devices and prosthetic devices. The report must:
25(1) be on a form prescribed by the commissioner; and
26(2) include the total number of claims and the total amount of
27claims paid for the services required under section 5 of this
28chapter during the preceding plan year.
29     (b) This section expires June 30, 2028.
30     SECTION 16. IC 27-13-7-19, AS ADDED BY P.L.109-2008,
31 SECTION 3, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
32 JULY 1, 2026]: Sec. 19. (a) This section applies to an individual
33 contract and a group contract that is entered into, delivered,
34 amended, or renewed after June 30, 2026.
35     (a) (b) As used in this section, "orthotic device" means a medically
36 necessary custom fabricated brace or support that is designed as a
37 component of a prosthetic device.
38     (b) (c) As used in this section, "prosthetic device" means an
39 artificial leg or arm.
40     (c) (d) An individual contract or a group contract that provides
41 coverage for basic health care services must provide coverage for the
42 following:
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1      (1) An orthotic devices and device or a prosthetic devices,
2      including repairs or replacements, device that is determined by
3      the enrollee's provider to be the most appropriate model that
4      adequately meets the medical needs of the enrollee.
5      (1) are provided or performed by a person that is:
6(A) accredited as required under 42 U.S.C. 1395m(a)(20); or
7(B) a qualified practitioner (as defined in 42 U.S.C.
81395m(h)(1)(F)(iii));
9      (2) are An orthotic device or a prosthetic device that is
10      determined by the enrollee's physician provider to be medically
11      necessary to restore or maintain the enrollee's ability to perform
12      activities of daily living or essential job related activities; and the
13      most appropriate model that meets the medical needs of the
14      enrollee for purposes of:
15(A) performing physical activities, as applicable, such as
16running, biking, swimming, and strength training; and
17(B) maximizing the enrollee's whole body health and lower
18or upper limb function.
19      (3) are not solely for comfort or convenience. An orthotic device
20      or a prosthetic device that is determined by the enrollee's
21      provider to be the most appropriate model that meets the
22      medical needs of the enrollee for purposes of showering or
23      bathing.
24      (4) All materials and components necessary to use the orthotic
25      devices and prosthetic devices described in subdivisions (1)
26      through (3).
27      (5) Instruction to the enrollee on using the orthotic devices
28      and prosthetic devices described in subdivisions (1) through
29      (3).
30      (6) The medically necessary repair or replacement of the
31      orthotic devices and prosthetic devices described in
32      subdivisions (1) through (3).
33    (e) With respect to an enrollee who receives an orthotic device
34 or a prosthetic device under subsection (d)(1), coverage of an
35 additional orthotic device or prosthetic device under subsection
36 (d)(2) or (d)(3) must require the enrollee's treating physician to
37 determine that the additional orthotic device or prosthetic device
38 under subsection (d)(2) or (d)(3) is necessary to enable the enrollee
39 to engage in the activities described in subsection (d)(2) or (d)(3).
40    (d) (f) The:
41      (1) coverage required under subsection (c) (d) must be equal to
42      the coverage that is provided for the same device, repair, or
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                                    11
1replacement under the federal Medicare program (42 U.S.C. 1395
2et seq.) and the regulations under 42 CFR 410.100, 42 CFR
3414.202, 42 CFR 414.210, and 42 CFR 414.228; and
4(2) reimbursement under the coverage required under subsection
5(c) (d) must be equal to the reimbursement that is provided for the
6same device, repair, or replacement under the federal Medicare
7reimbursement schedule, unless a different reimbursement rate is
8negotiated.
9 This subsection does not require a deductible under an individual
10 contract or a group contract to be equal to a deductible under the
11 federal Medicare program.
12    (e) (g) Except as provided in subsections (f) and (g), subsection (i),
13 the coverage required under subsection (c): (d):
14(1) may be subject to; and
15(2) may not be more restrictive than;
16 the provisions that apply to other benefits under the individual contract
17 or group contract.
18    (h) An individual contract or a group contract shall consider the
19 coverage required under subsection (d) to be habilitative or
20 rehabilitative benefits for purposes of any state or federal
21 requirement for coverage of essential health benefits.
22    (f) (i) The coverage required under subsection (c) (d) may be
23 subject to utilization review, including periodic review, of the
24 continued medical necessity of the benefit. An individual contract or
25 a group contract:
26(1) shall render utilization review determinations in a
27nondiscriminatory manner; and
28(2) may not deny coverage for habilitative or rehabilitative
29benefits, including orthotic devices or prosthetic devices,
30solely on the basis of an enrollee's actual or perceived
31disability.
32    (j) An individual contract or a group contract may not deny
33 coverage for an orthotic device or a prosthetic device for an
34 enrollee with limb loss or absence that would otherwise be covered
35 for an enrollee without a disability who seeks medical or surgical
36 intervention to restore or maintain the ability to perform the same
37 physical activity.
38    (k) An individual contract or a group contract shall include
39 language describing an enrollee's rights under subsections (i) and
40 (j) in the individual contract or group contract's evidence of
41 coverage and any denial letters.
42    (l) An individual contract or a group contract shall ensure that
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                                   12
1 enrollees have access to medically necessary clinical care and
2 orthotic devices and prosthetic devices from at least two (2) distinct
3 orthotic device and prosthetic device providers in the individual
4 contract or group contract's network. If medically necessary
5 orthotic devices and prosthetic devices are not available from an
6 in network provider, the individual contract or group contract
7 shall:
8(1) provide processes to refer an enrollee to an out of network
9provider; and
10(2) fully reimburse the out of network provider at a mutually
11agreed upon rate reduced by the enrollee's cost sharing
12determined on an in network basis.
13     (m) If an individual contract or a group contract provides
14 coverage for an orthotic device or prosthetic device, the individual
15 contract or group contract shall provide coverage for the
16 replacement of the orthotic device, the prosthetic device, or any
17 part of the orthotic device or prosthetic device without regard to
18 continuous use or useful lifetime restrictions if an ordering
19 provider determines that the replacement device or part is
20 necessary because of any of the following:
21(1) A change in the physiological condition of the enrollee.
22(2) An irreparable change in the condition of the device or
23part.
24(3) The condition of the device or part requires repairs and
25the cost of the repairs would be more than sixty percent
26(60%) of the cost of a replacement device or part.
27 The individual contract or group contract may require
28 confirmation from a prescribing provider if the device or part that
29 is being replaced is less than three (3) years old.
30     (g) Any lifetime maximum coverage limitation that applies to
31 prosthetic devices and orthotic devices:
32(1) must not be included in; and
33(2) must be equal to;
34 the lifetime maximum coverage limitation that applies to all other items
35 and services generally under the individual contract or group contract.
36     (h) (n) For purposes of this subsection, "items and services" does
37 not include preventive services for which coverage is provided under
38 a high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26
39 U.S.C. 223(c)(2)). The coverage required under subsection (c) (d) may
40 not be subject to a deductible, copayment, or coinsurance provision that
41 is less favorable to an enrollee than the deductible, copayment, or
42 coinsurance provisions that apply to other items and services generally
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                                 13
1 under the individual contract or group contract.
2    (o) Not later than October 1, 2027, a health maintenance
3 organization that enters into an individual contract or a group
4 contract that provides coverage for basic health care services shall
5 submit a report to the commissioner regarding the individual
6 contract or group contract's coverage of orthotic devices and
7 prosthetic devices. The report must:
8      (1) be on a form prescribed by the commissioner; and
9      (2) include the total number of claims and the total amount of
10      claims paid for the services required under subsection (d)
11      during the preceding plan year.
12 This subsection expires June 30, 2028.
 2026  IN 72—LS 6216/DI 141