text: SECTION 1. SHORT TITLE.
  
      This Act may be cited as the ``Prosthetic and Custom Orthotic 
  Parity Act of 2009''.
  
  SEC. 2. FINDINGS; PURPOSE.
  
      (a) Findings.--Congress finds the following:
              (1) There are more than 1,800,000 people in the United 
          States living with limb loss.
              (2) Every year, there are more than 130,000 people in the 
          United States who undergo amputation.
              (3) In addition, United States military personnel serving 
          in Iraq and Afghanistan and around the world have sustained 
          traumatic injuries resulting in amputation.
              (4) The number of amputations in the United States is 
          projected to increase in the years ahead due to rising 
          incidence of diabetes and other chronic illness.
              (5) Those suffering from limb loss can and want to regain 
          their lives as productive members of society.
              (6) Prosthetic devices enable amputees to continue working 
          and living productive lives.
              (7) Insurance companies have begun to limit reimbursement 
          of prosthetic equipment costs at unrealistic levels or not at 
          all and often restrict coverage over a person's lifetime, which 
          shifts costs onto the Medicare and Medicaid programs.
              (8) Eleven States have addressed this problem and have 
          enacted prosthetic parity legislation.
              (9) Prosthetic parity legislation has been introduced and 
          is being actively considered in 30 States.
              (10) The States in which prosthetic parity laws have been 
          enacted have found there to be minimal or no increases in 
          insurance premiums and have reduced Medicare and Medicaid 
          costs.
              (11) Prosthetic parity legislation will not add to the size 
          of government or to the costs associated with the Medicare or 
          Medicaid programs.
              (12) If coverage for prosthetic devices and components are 
          offered by a group health insurance policy, then providing such 
          coverage of prosthetic devices on par with other medical and 
          surgical benefits will not increase the incidence of 
          amputations or the number of individuals for which a prosthetic 
          device would be medically necessary and appropriate.
              (13) In States where prosthetic parity legislation has been 
          enacted, amputees are able to return to a productive life, 
          State funds have been saved, and the health insurance industry 
          has continued to prosper.
              (14) Prosthetic services allow people to return more 
          quickly to their preexisting work.
              (15) Spina bifida occurs in 7 out of every 10,000 live 
          births in the United States.
              (16) For children with spina bifida, access to a custom 
          orthotic device impacts both their short and long term 
          mobility, their muscle strength, and overall quality of life. 
          As they mature, the orthotic device allows them to maintain 
          their maximum level of functionality. This has a profound 
          impact on their ability to become and remain independent and 
          productive members of the community.
              (17) Cerebral palsy is one of the most common congenital 
          (existing before birth or at birth) disorders of childhood. 
          About 10,000 babies per year in the United States will develop 
          cerebral palsy.
              (18) The purpose of a custom orthotic device for people 
          with cerebral palsy is to protect, such as stabilizing a 
          fracture during healing; to prevent deformity, such as 
          stretching braces worn while the person sleeps, to help prevent 
          muscle contractures; and to improve function. This can help 
          kids with cerebral palsy achieve maximum potential in growth 
          and development.
              (19) If coverage for prosthetic and custom orthotic devices 
          and related services is offered to individuals by a group 
          health insurance policy, then providing such coverage of 
          prosthetic and orthotic devices on par with other medical and 
          surgical benefits will not increase the incidence of 
          amputations or the number of individuals for which a prosthetic 
          or custom orthotic device would be medically necessary and 
          appropriate.
      (b) Purpose.--The purpose of this Act is to require that each group 
  health plan that provides both coverage for prosthetic devices and 
  components and medical and surgical benefits, provide such coverage 
  under terms and conditions that are no less favorable than the terms 
  and conditions under which such benefits are provided under such plan.
  
  SEC. 3. PROSTHETICS AND CUSTOM ORTHOTIC DEVICE PARITY UNDER ERISA.
  
      (a) In General.--Subpart B of part 7 of subtitle B of title I of 
  the Employee Retirement Income Security Act of 1974 is amended by 
  inserting after section 713 (29 U.S.C. 1185b) the following new 
  section:
  
  ``SEC. 715. PROSTHETICS AND CUSTOM ORTHOTIC DEVICE PARITY.
  
      ``(a) In General.--In the case of a group health plan (or health 
  insurance coverage offered in connection with such a plan) that 
  provides both medical and surgical benefits and benefits for prosthetic 
  devices and components and orthotic devices (as defined under 
  subsection (d)(1))--
              ``(1) such benefits for prosthetic devices and components 
          and custom orthotic devices and related services under the plan 
          (or coverage) shall be provided under terms and conditions that 
          are no less favorable than the terms and conditions applicable 
          to substantially all medical and surgical benefits provided 
          under the plan (or coverage);
              ``(2) such benefits for prosthetic devices and components 
          and custom orthotic devices and related services under the plan 
          (or coverage) may not be subject to separate financial 
          requirements (as defined in subsection (d)(2)) that are 
          applicable only with respect to such benefits, and any 
          financial requirements applicable to such benefits may be no 
          more restrictive than the financial requirements applicable to 
          substantially all medical and surgical benefits provided under 
          the plan (or coverage); and
              ``(3) any treatment limitations (as defined in subsection 
          (d)(3)) applicable to such benefits for prosthetic devices and 
          components and custom orthotic devices and related services 
          under the plan (or coverage) may not be more restrictive than 
          the treatment limitations applicable to substantially all 
          medical and surgical benefits provided under the plan (or 
          coverage).
      ``(b) In-Network and Out-of-Network Standards.--
              ``(1) In general.--In the case of a group health plan (or 
          health insurance coverage offered in connection with such a 
          plan) that provides both medical and surgical benefits and 
          benefits for prosthetic devices and components and custom 
          orthotic devices and related services, and that provides both 
          in-network benefits for prosthetic devices and components and 
          out-of-network benefits for prosthetic devices and components, 
          the requirements of this section shall apply separately with 
          respect to benefits provided under the plan (or coverage) on an 
          in-network basis and benefits provided under the plan (or 
          coverage) on an out-of-network basis.
              ``(2) Clarification.--Nothing in paragraph (1) shall be 
          construed as requiring that a group health plan (or health 
          insurance coverage offered in connection with such a plan) 
          eliminate an out-of-network provider option from such plan (or 
          coverage) pursuant to the terms of the plan (or coverage).
      ``(c) Additional Requirements.--
              ``(1) Prior authorization.--In the case of a group health 
          plan (or health insurance coverage offered in connection with 
          such a plan) that requires, as a condition of coverage or 
          payment for prosthetic devices and custom orthotic devices and 
          related services under the plan (or coverage), prior 
          authorization, such prior authorization must be required in the 
          same manner as prior authorization is required by the plan (or 
          coverage) as a condition of coverage or payment for all similar 
          benefits provided under the plan (or coverage).
              ``(2) Limitation on mandated benefits.--Required benefits 
          for prosthetic devices and custom orthotic devices and related 
          services under this section are limited to the most appropriate 
          model that adequately meets the medical requirements of the 
          patient, as determined by the treating physician of the 
          patient.
              ``(3) Coverage for repair or replacement.--Benefits for 
          prosthetic devices and custom orthotic devices and related 
          services required under this section shall include coverage for 
          repair or replacement of prosthetic devices and components, if 
          the repair or replacement is determined appropriate by the 
          treating physician of the patient involved.
              ``(4) Annual or lifetime dollar limitations.--A group 
          health plan (or health insurance coverage offered in connection 
          with such a plan) may not impose any annual or lifetime dollar 
          limitation on benefits for prosthetic devices and custom 
          orthotic devices and related services unless such limitation 
          applies in the aggregate to all medical and surgical benefits 
          provided under the plan (or coverage) and benefits for 
          prosthetic devices and components.
      ``(d) Definitions.--For the purposes of this section:
              ``(1) Prosthetic devices and components.--The term 
          `prosthetic devices and components' means such devices and 
          components which may be used to replace, in whole or in part, 
          an arm or leg, as well as the services required to do so, and 
          includes external breast prostheses incident to mastectomy 
          resulting from breast cancer.
              ``(2) Custom orthotic devices and related services.--The 
          term `custom orthotic devices and related services' means the 
          following:
                      ``(A) Custom-fabricated orthotics and related 
                  services, which include custom-fabricated devices that 
                  are individually made for a specific patient, as well 
                  as all services and supplies medically necessary for 
                  the effective use of the orthotic device, including 
                  formulating its design, fabrication, material and 
                  component selection, measurements, fittings, and static 
                  and dynamic alignments, and instructing the patient in 
                  the use of the device. No other patient would be able 
                  to use this item. A custom fabricated item is a device 
                  which is fabricated based on clinically derived and 
                  rectified castings, tracings, measurements, and/or 
                  other images (such as x-rays) of the body part. The 
                  fabrication may involve using calculations, templates 
                  and components. This process requires the use of basic 
                  materials including, but not limited to plastic, metal, 
                  leather or cloth in the form of uncut or unshaped 
                  sheets, bars, or other basic forms and involves 
                  substantial work such as vacuum forming, cutting, 
                  bending, molding, sewing, drilling and finishing prior 
                  to fitting on the patient. Custom-fabricated devices 
                  may be furnished only by an appropriately credentialed 
                  (certified or licensed) practitioner or accredited 
                  supplier in orthotics and/or prosthetics. These devices 
                  and services are represented by the existing set of L-
                  codes describing this care currently listed in Centers 
                  for Medicare and Medicaid Services Transmittal 656.
                      ``(B) Custom-fitted high orthotics and related 
                  services, which include prefabricated devices that are 
                  manufactured with no specific patient in mind, but that 
                  are appropriately sized, adapted, modified, and 
                  configured (with the required tools and equipment) to a 
                  specific patient in accordance with a prescription, and 
                  which no other patient would be able to use, as well as 
                  all services and supplies medically necessary for the 
                  effective use of the orthotic device, including 
                  formulating its design, fabrication, material and 
                  component selection, measurements, fittings, and static 
                  and dynamic alignments, and instructing the patient in 
                  the use of the device. Custom-fitted high devices may 
                  be furnished only by an appropriately credentialed 
                  (certified or licensed) practitioner or accredited 
                  supplier in orthotics and/or prosthetics. These devices 
                  and services are represented by the existing set of L-
                  codes describing this care currently listed in Centers 
                  for Medicare and Medicaid Services Transmittal 656.
              ``(3) Financial requirements.--The term `financial 
          requirements' includes deductibles, coinsurance, co-payments, 
          other cost sharing, and limitations on the total amount that 
          may be paid by a participant or beneficiary with respect to 
          benefits under the plan or health insurance coverage and also 
          includes the application of annual and lifetime limits.
              ``(4) Treatment limitations.--The term `treatment 
          limitations' includes limits on the frequency of treatment, 
          number of visits, days of coverage, or other similar limits on 
          the scope or duration of treatment.''.
      (b) Clerical Amendment.--The table of contents in section 1 of such 
  Act is amended by inserting after the item relating to section 713 the 
  following new item:
  
  ``Sec. 715. Prosthetics and custom orthotic device parity.''.
      (c) Effective Date.--The amendments made by this section shall 
  apply with respect to group health plans (and health insurance coverage 
  offered in connection with group health plans) for plan years beginning 
  on or after the date of the enactment of this Act.
  
  SEC. 4. FEDERAL ADMINISTRATIVE RESPONSIBILITIES.
  
      (a) Assistance to Plan Participants and Beneficiaries.--The 
  Secretary of Labor shall provide for assistance to participants and 
  beneficiaries under such plans with any questions or problems regarding 
  compliance with the requirements of this section.
      (b) Audits.--The Secretary of Labor shall provide for the conduct 
  of random audits of group health plans (and health insurance coverage 
  offered in connection with such plans) to ensure that such plans are in 
  compliance with section 715 of the Employee Retirement Income Security 
  Act of 1974, as added by section 3.
      (c) GAO Study.--
              (1) Study.--The Comptroller General of the United States 
          shall conduct a study that evaluates the effect of the 
          implementation of the amendments made by this Act on the cost 
          of health insurance coverage, on access to health insurance 
          coverage (including the availability of in-network providers), 
          on the quality of health care, on benefits and coverage for 
          prosthetic devices and components, on any additional cost or 
          savings to group health plans, on State prosthetic devices and 
          components benefit mandate laws, on the business community and 
          the Federal Government, and on other issues as determined 
          appropriate by the Comptroller General.
              (2) Report.--Not later than 2 years after the date of the 
          enactment of this Act, the Comptroller General of the United 
          States shall prepare and submit to the appropriate committees 
          of Congress a report containing the results of the study 
          conducted under paragraph (1).
      (d) Regulations.--Not later than 1 year after the date of the 
  enactment of this Act, the Secretary of Labor shall promulgate final 
  regulations to carry out this Act and the amendments made by this Act.
target: Prosthetic and Custom Orthotic Parity Act of 2009 - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to require a group health plan that provides medical and surgical benefits as well as benefits for prosthetic devices and components and orthotic devices to offer such prosthetic and orthotic coverage in the same manner as applicable to medical and surgical benefits. Prohibits separate financial requirements or more restrictive treatment limitations.
  
  Limits required benefits for prosthetic devices and custom orthotic devices and related services to the most appropriate model that adequately meets the medical requirements of the patient. Requires benefits to include repairs and replacements as determined appropriate by the treating physician.
  
  Prohibits any annual or lifetime dollar limitation on benefits for prosthetic devices and custom orthotic devices and related services unless such limitation applies in the aggregate to all benefits.
feat_title: To provide parity under group health plans and group health insurance coverage in the provision of benefits for prosthetic devices and orthotics devices, components and benefits for other medical and surgical services.