HB 1235

ENROLLED
 2026 Regular Session
  ACT No. 719
 HOUSE BILL NO. 1235  (Substitute for House Bill No. 477 by Representative Hebert)
 BY REPRESENTATIVES HEBERT, ADAMS, BAYHAM, BOUDREAUX, BOYD,
  BRASS, CHASSION, COX, FISHER, FREIBERG, JACKSON, MIKE JOHNSON,
  LAFLEUR, JACOB LANDRY, LARVADAIN, LYONS, MELERINE, MOORE,
  NEWELL, SPELL, TAYLOR, WALTERS, AND WILEY
1AN ACT
2 To amend and reenact R.S. 22:1049 and to enact Part IX of Chapter 5-E of Title 40 of the
3Louisiana Revised Statutes of 1950, to be comprised of R.S. 40:1259.11, relative to
4health insurance; to require coverage for prosthetic and orthotic devices and
5associated services; to establish criteria for medical necessity determinations; to
6delineate coverage standards, encompassing multiple devices, materials,
7components, repair, and replacement; to provide requirements for prior authorization
8and cost-sharing; to provide nondiscrimination provisions; to provide for network
9adequacy standards; to set reporting requirements; to provide for definitions; and to
10provide for related matters.
11 Be it enacted by the Legislature of Louisiana:
12Section 1. R.S. 22:1049 is hereby amended and reenacted to read as follows:
13§1049. Requirement for coverage of prosthetic and orthotic devices and prosthetic
14services
15A. Notwithstanding the provisions of R.S. 22:1047 to the contrary, any Any
16health coverage plan specified in Subsection H K of this Section which is issued for
17delivery, delivered, renewed, or otherwise contracted for in this state on or after
18January 1, 2009, shall provide coverage of prosthetic and orthotic devices and
19prosthetic and orthotic services as further provided in this Section.
20B.(1)(a) Eligibility and limits of coverage for prosthetic and orthotic devices
21and prosthetic services shall be determined by the health coverage plan, in
22consultation with the enrollee's medical providers and their assessment of based on
23medical necessity.
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1(b) In determining medical necessity, the health coverage plan shall consider
2the recommendations by the insured's physician or advanced practice provider. Such
3recommendations shall be based on the most appropriate prosthesis or orthosis that
4adequately meets the medical needs of the insured to restore or maintain the ability
5to perform activities of daily living and essential job-related functions.
6(2) The coverage shall, at a minimum, equal the coverage and prevailing
7payment rate for prosthetic and orthotic devices provided under federal laws and
8regulations for the aged and disabled pursuant to 42 U.S.C. 1395k, 1395l, and 1395m
9and 42 CFR 414.202, 414.210, 414.228, and 410.100.
10(3) In accordance with Subsection C of this Section, covered benefits shall
11be provided for more than one prosthesis or orthosis when determined by the health
12coverage plan to be medically necessary and may not exclude coverage for prosthetic
13or orthotic devices designed for physical activity or showering and bathing pursuant
14to blanket exclusions of items used for recreation or leisure, athletic or sports
15purposes, or luxury or convenience.
16(4)(a) Any denial or limit of coverage based on lack of medical necessity
17may be appealed in accordance with R.S. 22:1121 R.S. 22:2391 et seq.
18(b) With respect to claim denials based on medical necessity, such denials
19shall be in writing and include clear reasoning and descriptions of how and why the
20request or claim does not meet medical necessity standards.
21(c) Such medical necessity determination shall consider information and
22recommendation from the treating physician in consultation with the insured,
23including but not limited to information in the medical record of the treating
24prosthetist or orthotist and the results of a functional limit test assessment. Such test
25assessment shall consider but not be limited to the following factors:
26(1) (i) The insured's past history, including prior use of prosthetic or orthotic
27devices if applicable.
28(2) (ii) The insured's current condition, including the status of the residual
29limb and the nature of other medical problems.
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1(3) (iii) The insured's desire to ambulate, with respect to lower limb
2prosthetic devices, or maximize upper limb function, with respect to upper limb
3prosthetic devices, and the insured's desire and ability to use an prosthesis or orthosis
4to maintain maximum function.
5C.(1) In addition to the primary prosthetic or orthotic device of the upper or
6lower extremity, the health coverage plan shall provide coverage for an additional
7upper or lower extremity prosthetic or orthotic device when:
8(a) The treating physician or other advanced practice provider determines
9that the additional prosthesis or orthosis is necessary to enable the enrollee to engage
10in physical activities, as applicable, such as running, biking, swimming, strength
11training, showering, or bathing, and to maximize the enrollee's whole-body health
12and lower and upper limb function.
13(b) The single additional prosthetic or orthotic device is determined to be
14medically necessary by the health coverage plan as being the most appropriate device
15to meet the insured's medical needs for purposes of performing physical activities
16such as running, biking, swimming, strength training, and other similar activities.
17(c) This Subsection does not require coverage for a replacement of the
18additional prosthetic or orthotic device of the upper or lower extremity unless
19determined by the health coverage plan, in consultation with the enrollee's medical
20providers, to be medically necessary.
21(2)   If neither the original prosthetic or orthotic devices described in
22Subsection B of this Section nor the additional upper or lower extremity prosthetic
23or orthotic device provided in Paragraph (C)(1) of this Section is sufficient to enable
24the insured to safely engage in bathing and showering, then in addition to those
25devices, a single additional prosthetic or orthotic device recommended by the
26insured's physician or other advanced practice provider for purposes of showering
27or bathing shall be covered when determined to be medically necessary to enable the
28enrollee to safely engage in those activities.
29C. D.(1)    A health coverage plan may require prior authorization for
30prosthetic and orthotic devices and prosthetic services in the same manner that prior
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1authorization is required for any other covered benefit, if such procedures are
2rendered in a nondiscriminatory manner.
3(2) Utilization review procedures shall not deny coverage for habilitative or
4rehabilitative benefits, including prosthetics or custom orthotics, solely on the basis
5of an insured's actual or perceived disability.
6(3) An insurer shall not deny a prosthetic or custom-orthotic benefit for an
7individual with limb loss, limb absence, or limb impairment that would otherwise be
8covered for a non-disabled person seeking medical or surgical intervention to restore
9or maintain the ability to perform the same physical activity.
10D. E. A health coverage plan may impose co-payments, deductibles, or
11coinsurance amounts on prosthetic and orthotic devices and prosthetic services. The
12co-payments shall not be greater than the co-payments that apply to other benefits
13under the plan.
14F.(1) The repair and replacement of prosthetic and orthotic devices also shall
15be covered subject to co-payments, coinsurance, and deductibles that are no more
16restrictive than the co-payments, coinsurance, and deductibles that apply to other
17benefits under the plan, unless necessitated by misuse theft or loss.
18(2) Coverage of repair or replacement of prosthetic and orthotic devices,
19subject to coverage as outlined in Subsection B of this Section shall meet medical
20necessity requirements of the health coverage plan and be recommended by the
21treating healthcare provider.
22(3) The treating healthcare provider may recommend that replacement of the
23device is required if any of the following apply:
24(a) There is a change in the physiological condition of the enrollee.
25(b) There is an irreparable change in the condition of the device or any
26component of the device.
27(c) The condition of the device requires repairs that are too extensive to be
28cost effective in accordance with the health coverage plan's guidelines.
29G. A health plan that provides coverage for prostheses or orthoses shall
30ensure access to medically necessary clinical care and to prostheses and custom
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1orthoses from not less than two distinct prosthetic and orthotic providers in the
2managed care plan's provider network located in the state. In the event that
3medically necessary covered orthoses and prostheses are not available from an
4in-network provider, the insurer shall provide processes to refer a member to an
5out-of-network provider and shall fully reimburse the out-of-network provider at a
6mutually agreed upon rate less member cost sharing determined on an in-network
7basis.
8E. H. A health coverage plan shall include a requirement that prosthetic and
9orthotic devices be provided by an accredited facility and a requirement that
10prosthetic and orthotic services be prescribed by a licensed physician and provided
11by an accredited facility.
12F. I. Coverage of prosthetic and orthotic devices and prosthetic services may
13be made subject to but no more restrictive than the provisions of a health coverage
14plan that apply to other benefits under the plan. An individual health plan that is
15delivered, issued for delivery, or renewed in this state that covers prostheses and
16custom orthoses shall consider these benefits rehabilitative and habilitative services
17and devices for purposes of any state or federal requirement for coverage of essential
18health benefits.
19G.(1) A health coverage plan may apply an annual limit of benefits payable
20under this Section of no less than fifty thousand dollars per limb.
21(2) This Subsection does not prohibit a health benefit plan from providing
22coverage that is greater or more favorable to an insured than the requirements of this
23Subsection.
24(3) An insured may choose a prosthetic device that is priced higher than the
25benefit payable under the health benefit plan and may pay the difference between the
26price of the device and the benefit payable, without financial or contractual penalty
27to the provider of the device.
28J. A health coverage plan subject to this Section shall report to the
29commissioner on its experience pursuant to this Section for plan years 2027-2028.
30The report shall be in a form prescribed by the commissioner and shall include the
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1number of claims and the total amount of claims paid in this state for the services
2required under this Section. The commissioner shall aggregate this data by plan year
3in a report and submit the report to the House and Senate committees on insurance
4no later than July 1, 2029.
5H K. As used in the Section:
6(1) "Accredited facility" means any entity that is accredited by the American
7Board for Certification in Orthotics, Prosthetics and Pedorthics (ABC) or by the
8Board for Orthotist/Prosthetist Certification (BOC) and that provides prosthetic
9devices or prosthetic services.
10(2) "Advanced practice provider" means a healthcare professional who is
11licensed in this state and authorized under state law to evaluate patients and prescribe
12prosthetic and orthotic devices within the provider's scope of practice.
13(2) (3) "Health coverage plan" shall mean any hospital, health, or medical
14expense insurance policy, hospital or medical service contract, employee welfare
15benefit plan, contract or agreement with a health maintenance organization or a
16preferred provider organization, health and accident insurance policy, or any other
17insurance contract of this type, including a group insurance plan and the Office of
18Group Benefits programs.
19(4)    "Orthotic device" or "Orthosis" means a custom-designed,
20custom-fabricated, custom-fitted, or modified device to treat a neuromusculoskeletal
21disorder or acquired condition. For purposes of this Section, orthosis shall be limited
22to devices utilized for the upper or lower limbs.
23(5)   "Orthotic services" means the science and practice of evaluating,
24measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or
25servicing a custom orthosis. Prosthetists, orthotic assistants, and orthotic fitters who
26are credentialed by a nationally recognized Orthotic, Prosthetic and Pedorthic
27certifying board or are licensed, if applicable, may be privileged based on written
28objective criteria to provide orthotic care. Certified or licensed pedorthists may be
29privileged based on written objective criteria to provide lower extremity orthotic
30care.
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1(3) (6) "Prosthetic device" or "prosthesis" means an artificial limb designed
2to maximize function, stability, and safety of the patient. Prosthetic device or
3prosthesis also means an artificial medical device that is not surgically implanted and
4that is used to replace a missing limb. The term does not include artificial eyes, ears,
5noses, dental appliances, ostomy products, or devices such as eyelashes or wigs.
6(4) (7) "Prosthetic services" means the science and practice of evaluating,
7measuring, designing, fabricating, assembling, fitting, aligning, adjusting, or
8servicing of a prosthesis through the replacement of external parts of a human body
9lost due to amputation or congenital deformities to restore function, cosmesis, or
10both. It shall also include any medically necessary clinical care.
11I L. The provisions of this Section shall not apply to limited benefit health
12insurance, short-term policies, or contracts.
13Section 2. Part IX of Chapter 5-E of Title 40 of the Louisiana Revised Statutes of
14 1950, comprised of R.S. 40:1259.11, is hereby enacted to read as follows:
15  PART IX. PROSTHETIC AND CUSTOM ORTHOTIC DEVICES AND SERVICES
16COVERAGE
17§1259.11. Prosthetic and custom orthotic devices and services; Medicaid coverage
18A. The Louisiana Medicaid program shall provide coverage for prosthetic
19and custom orthotic devices and services to an enrollee when such devices or
20services are deemed medically necessary in accordance with the standards and
21clinical criteria set forth by the Medicaid program.
22B.   Coverage includes the devices, services, materials, components,
23instruction, repair, and replacement as delineated in R.S. 22:1049, including but not
24limited to services required to restore or maintain the ability to perform activities of
25daily living, essential job-related functions, and medically necessary physical
26activity. The definitions provided in R.S. 22:1049 apply to this Section unless the
27context clearly requires otherwise.
28C. Pursuant to this Section, the secretary of the Louisiana Department of
29Health shall do all of the following:
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1(1) Submit to the Centers for Medicare and Medicaid Services all necessary
2state plan amendments.
3(2) Promulgate all necessary rules and regulations in accordance with the
4Administrative Procedure Act.
5(3) Take any other actions necessary to implement the provisions of this
6Chapter.
7Section 3. The coverage requirements provided by the provisions of this Act as
8 enacted by Section 1 of this Act shall apply to any new health coverage plan delivered,
9 issued for delivery, or otherwise contracted for in this state beginning on or after January 1,
10 2027. Any health coverage policy, contract, or plan in effect prior to January 1, 2027, shall
11 convert to conform to the provisions of Section 1 of this Act upon renewal, on or before the
12 renewal date, but no later than January 1, 2028.
13Section 4. The report required to be compiled and submitted to the commissioner
14 of insurance as required by the provisions of R.S. 22:1049(J) as enacted by Section 1 of this
15 Act shall be due beginning July 1, 2029.
16Section 5. This Act shall become effective upon signature by the governor or, if not
17 signed by the governor, upon expiration of the time for bills to become law without signature
18 by the governor, as provided by Article III, Section 18 of the Constitution of Louisiana. If
19 vetoed by the governor, and subsequently approved by the legislature, this Act shall become
20 effective on the day following such approval.
  SPEAKER OF THE HOUSE OF REPRESENTATIVES
  PRESIDENT OF THE SENATE
  GOVERNOR OF THE STATE OF LOUISIANA
 APPROVED:
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