As Introduced

136th General Assembly

Regular Session H. B. No. 564

2025-2026

To enact sections 3902.65, 3902.651, 3902.652, 3902.653, and 3902.654 of the Revised Code to require health insurance coverage of orthotic and prosthetic devices.

BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO:

Section 1. That sections 3902.65, 3902.651, 3902.652, 3902.653, and 3902.654 of the Revised Code be enacted to read as follows:

Sec. 3902.65. (A) For the purposes of sections 3902.65 to 3902.654 of the Revised Code, "qualifying health benefit plan" means a health benefit plan issued, amended, or renewed in this state on or after the effective date of this section, and that provides coverage for hospital, medical, or surgical expenses. A health benefit planned is "renewed" for the purposes of this division not later than the first anniversary of the original contract date that occurs on or after the effective date of this section.

(B) Notwithstanding section 3901.71 of the Revised Code, a qualifying health benefit plan shall provide coverage for prosthetic and orthotic devices that, at a minimum, equals the coverage and payment for prosthetic and orthotic devices provided under federal laws and regulations for the aged and disabled pursuant to 42 U.S.C. 1395k, 1395l, and 1395m, and 42 C.F.R. 410.100, 414.202, 414.210, and 414.228. The coverage shall include both of the following:

(1) Coverage for the purchase, fitting, adjustment, repair, and replacement of one or more prosthetic or orthotic devices as needed to accomplish both of the following, as applicable:

(a) The replacement of all or part of a missing body part and its adjoining tissues;

(b) The replacement of, when possible, all of the function of a permanently useless or malfunctioning body part as necessary to do all of the following:

(i) Complete activities of daily living or essential job-related activities;

(ii) Perform physical activities such as running, biking, swimming, or strength training, and to maximize the covered person's whole-body health and lower and upper limb function;

(iii) Showering or bathing.

(2) Coverage for both of the following with respect to the devices described in division (B)(1) of this section:

(a) All materials and components necessary to use the devices;

(b) Instruction to a covered person on using the devices.

(C) A health plan issuer may impose utilization review procedures with regard to coverage provided under division (B) of this section, provided that such review is not applied in a discriminatory manner solely on the basis of a covered person's actual or perceived disability.

(D) For purposes of any state or federal requirement for coverage of essential health benefits, coverage of a prosthetic or orthotic device shall be considered a habilitative or rehabilitative benefit.

(E) With respect to a covered person, coverage of one or more prosthetic or orthotic devices is medically necessary if it is determined by a covered person's provider to be the most appropriate model that adequately meets the medical needs of the covered person, including any orthotic or prosthetic devices that enable the covered person to do any or all of the following:

(1) Completing activities of daily living or essential job-related activities;

(2) Performing physical activities, such as running, biking, swimming, or strength training;

(3) Maximizing the covered person's whole-body health;

(4) Maximizing the covered person's lower or upper limb function;

(5) Showering or bathing.

(F) A health plan issuer shall render utilization review determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of a covered person's actual or perceived disability.

(G) A health plan issuer shall not deny a prosthetic or orthotic benefit for a covered person with limb loss, absence, or difference that would otherwise be covered for a nondisabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.

(H)(1) A qualifying health benefit plan shall include language describing a covered person's rights under this section in its evidence of coverage and any benefit denial letters.

(2) With regard to prosthetic and orthotic device coverage, any denials of coverage or prior authorization or pre-determination decisions shall be issued in writing.

(I) Nothing in this section shall be construed as prohibiting a health plan issuer from imposing cost-sharing with regard to coverage of prosthetic or orthotic devices, provided that any cost-sharing requirements are not more restrictive than the cost-sharing requirements applicable to the plan's coverage for inpatient physician and surgical services. Prosthetic and orthotic device coverage shall not be made subject to separate cost-sharing requirements that are applicable only with respect to that coverage.

(J)(1) A qualifying health benefit plan shall ensure access to medically necessary clinical care and to prosthetic and orthotic devices and technology from not less than two distinct prosthetic and orthotic providers located in this state in the plan's provider network.

(2) In the event that medically necessary covered orthotics and prosthetics are not available from an in-network provider, a health plan issuer shall provide processes to refer a covered person to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate, less any applicable cost-sharing, determined on an in-network basis.

(K)(1) A qualifying health benefit plan shall provide coverage for the replacement of a prosthetic or orthotic device covered pursuant to this section, or for the replacement of any part of such a device, as applicable, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary due to any of the following:

(a) A change in the physiological condition of the covered person;

(b) An irreparable change in the condition of the device or in a part of the device;

(c) The condition of the device, or a part of the device, requires repairs and the cost of such repairs is more than sixty per cent of the cost of a replacement device or of the part being replaced.

(2) A health plan issuer may require, before covering a replacement prosthetic or orthotic device or part of such a device that is less than three years old, that a prescribing health care provider confirm the replacement.

Sec. 3902.651. Both of the following are unfair and deceptive practices in the business of insurance under sections 3901.19 to 3901.26 of the Revised Code:

(A) Canceling or changing premiums, benefits, or conditions under a qualifying health benefit plan on the basis of a covered person's actual or perceived disability;

(B) Denying a prosthetic or orthotic benefit under a qualifying health benefit plan for a covered person with limb loss, absence, or difference that would otherwise be covered for a nondisabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.

Sec. 3902.652. Not later than the first day of March of the second year that begins after the effective date of this section, and annually thereafter, each health plan issuer that issues a qualifying health benefit plan shall report to the superintendent of insurance on the health plan issuer's experience providing coverage pursuant to section 3902.65 of the Revised Code for the previous plan year. The report shall be in a form prescribed by the superintendent and shall include the number of claims made and the total amount of claims paid in this state for the services required by section 3902.65 of the Revised Code. The superintendent shall aggregate this data by plan year in the report and submit the report to the standing committees of the senate and the house of representatives having jurisdiction over health coverage and insurance matters.

Sec. 3902.653. (A) Not later than one year after the effective date of this section, and annually thereafter for five years, each health plan issuer that issues a health benefit plan in this state shall report to the superintendent of insurance on the health plan issuer's experience related to coverage provided under section 3902.65 of the Revised Code.

(B) The report shall be in a form prescribed by the superintendent and shall include, at minimum, the total number of claims made, as well as the total amount paid, in this state for the coverage required under section 3902.65 of the Revised Code.

(C) The superintendent shall aggregate the data received under this section by plan year and make a report to the standing committees of the senate and house of representatives having jurisdiction over insurance matters.

Sec. 3902.654. (A) Not later than one year after the effective date of this section, the superintendent of insurance shall issue public guidance on what care and devices are needed to restore full function for a covered person with limb loss, limb difference, or mobility impairment in relation to the coverage required under division (B)(1) of section 3902.65 of the Revised Code.

(B) The superintendent shall update this guidance as often as the superintendent deems necessary.

Section 2. Sections 3902.65, 3902.651, 3902.652, 3902.653, and 3902.654 of the Revised Code, as enacted by this act, shall take effect on January 1, 2027, and apply to health benefit plans issued, amended, or renewed on or after that date.