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Bill

SB 5629

Concerning coverage requirements for prosthetic limbs and custom orthotic braces.

2025-2026 Regular Session Introduced by Mike Chapman and 8 co-sponsors

Requires health plans to cover medically necessary prosthetic limbs and custom orthotic braces with related services, repairs, and replacements.

By resolution, returned to Senate Rules Committee for third reading.
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Bill Summary · SB 5629

SB 5629 — Summary: Coverage Requirements for Prosthetic Limbs and Custom Orthotic Braces

Status: Returned to Senate Rules Committee for third reading (by resolution, 04/27/2025). Introduced 02/03/2025. Passed Senate (third reading) 03/06/2025 (yeas 43, nays 6) after committee substitute and floor amendments.

Purpose

To require health plans to cover medically necessary prosthetic limbs and custom orthotic braces (including materials, fitting, instruction, repairs, and replacements) so enrollees with mobility‑impairing conditions or disabilities can complete activities of daily living, essential job duties, and physical activities that maximize limb function.

Key provisions

  • Effective date: applies to health plans issued or renewed on or after January 1, 2026.
  • Coverage required:
    • One or more prostheses per limb and one or more custom orthotic braces per limb when medically necessary to:
    • Complete activities of daily living or essential job-related activities; or
    • Perform physical activities (e.g., running, biking, swimming, strength training) to maximize lower/upper limb function.
    • Includes materials, components, related services, instruction, and reasonable repair/replacement.
  • Replacement and repair rules:
    • Coverage for repair/replacement without regard to continuous‑use or “useful lifetime” limits where medically necessary due to physiological change, irreparable device damage, or when repair cost > 60% of replacement cost.
    • If part/device being replaced is less than 3 years old, carrier may require confirmation from prescribing provider.
  • Non‑discrimination: Plans may not deny prosthetic or orthotic coverage for an enrollee with a disability if the same service would be covered for a nondisabled person seeking intervention to restore/maintain the same activity.
  • Utilization management: Plans may use normal utilization management and prior authorization; denials must be in writing with an explanation that coverage was not medically necessary.
  • Payment parity: Carriers must provide payment at least equal to the payment and coverage rules set in specified federal Medicare statutes and regulations (42 U.S.C. §§ 1395k–m; 42 C.F.R. §§ 414.202, 414.210, 414.228, 410.100).
  • Reporting: By July 1, 2028, carriers must report (per commissioner format) the number and total amount of claims paid in WA for plan years 2026–2027. Insurance Commissioner to aggregate and report to legislative committees by December 1, 2028.
  • Definitions: The bill defines “prosthetic limb/prosthesis” and “custom orthotic brace” (patient‑specific, medically necessary devices for mobility‑impairing conditions).

Who is affected

  • Primary: enrollees with mobility‑impairing conditions or disabilities who require prostheses or custom orthoses.
  • Secondary: health carriers, employers (depending on plan type), providers of prosthetic/orthotic services, and the Office of the Insurance Commissioner (for reporting).
  • Scope differences across versions:
    • Committee substitute and engrossed versions narrowly targeted large group or nongrandfathered group plans (with some exclusions for public employee plans).
    • The enrolled bill language (S-0881.1) broadens application and reenacts/amends RCW 41.05.017 to make plans under chapter 41.05 (public employee plans) subject to the requirements.

Legislative actions & next steps

  • Public hearing: 02/11/2025; Committee exec action: 02/21/2025 (majority do pass, minority do not pass).
  • Committee substitute adopted 03/06/2025; floor amendments adopted; passed Senate 03/06/2025 (43–6).
  • By resolution 04/27/2025 returned to Senate Rules Committee for third reading — bill not yet enrolled or enacted. Next steps depend on further Senate action, concurrence by the House (if amended), and final enactment.

Potential impacts to note

  • Increased access to replacement and higher‑functioning prosthetic/orthotic devices for covered enrollees.
  • Potentially increased claims costs for carriers, offset in part by the requirement that payment practices align with existing Medicare payment rules.
  • Administrative impacts for carriers (prior authorization processes, reporting to Insurance Commissioner) and for employers if plans are brought within scope.

Compiled from official sources — confirm details with the bill’s official record.

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