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Bill

Bill

A 11406

Requires certain health insurance coverage for prostheses and custom orthoses

2025 Regular Session

New York health plans would be required to cover prostheses and custom orthoses as medically necessary, reducing out-of-pocket costs and standardizing access.

REFERRED TO INSURANCE
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WeVote Research Nonpartisan
Bill Summary · A 11406

Bill overview

A11406 (2025-2026, New York) would require certain health insurance plans to cover prostheses and custom orthoses. The bill aims to ensure access to medically necessary artificial limbs and specialized braces or supports by mandating coverage within regulated insurance products.

Purpose and intent

  • Improve patient access to life-enhancing and potentially life-saving devices (prostheses) and custom orthoses.
  • reduce out-of-pocket costs and variability in coverage across plans.
  • standardize coverage to align with clinical needs and patient rehabilitation goals.

Key provisions and changes

  • Coverage requirement: Mandates that qualified health insurance policies cover prostheses and custom orthoses as medically necessary items.
  • Scope of devices: Applies to artificial limbs (prostheses) and custom-made orthopedic devices designed to support or correct musculoskeletal function.
  • Medical necessity standard: Coverage typically conditioned on a clinician’s determination of medical necessity for the device, consistent with standard practice guidelines.
  • Custom orthoses: Includes devices such as custom-made braces, supports, and orthotic devices tailored to an individual patient.
  • Reimbursement framework: Establishes or references procedures for payment, potential copayments, deductibles, and in-network vs out-of-network considerations, consistent with existing insurance terms.
  • Periodic review and documentation: Likely requires documentation of medical necessity and device specifications to verify eligibility for coverage.
  • Plan applicability: Applies to insurers regulated by New York state law; may specify types of plans (e.g., comprehensive major medical, supplemental, or HMOs/PPOs) and exclusions, if any, consistent with other mandated benefits.

Who would be affected

  • Individuals insured under New York-regulated health plans seeking prostheses or custom orthoses.
  • Healthcare providers (physicians, orthotists, prosthetists, and medical suppliers) who prescribe and fit prosthetic devices and orthoses.
  • Insurance issuers and managed care organizations operating in New York, due to required coverage terms.
  • Employers and groups offering health benefits in New York, depending on plan type and applicability.

Procedural and timeline aspects

  • Current action: Referred to the Senate or Assembly Insurance committee as of May 15, 2026, indicating the bill is moving through the legislative process.
  • Next steps: Committee review, potential amendments, floor votes in both houses, and eventual Governor's signature to become law. If enacted, the effective date would be defined in the final bill (often with a specified rollout period or phased implementation).

Potential impact and considerations

  • Positive impact on access to essential devices for patients with limb loss, congenital conditions, or musculoskeletal disabilities.
  • Potential cost implications for insurers, though coverage mandates may improve long-term outcomes and reduce overall costs by enabling proper rehabilitation.
  • Administrative considerations for providers and insurers to document medical necessity and process claims efficiently.
  • Possible need for clarifications in the final text on definitions (prosthesis, custom orthosis), duration of coverage, durability requirements, and exceptions.

If you’d like, I can compare A11406 to existing New York mandated-benefit statutes or provide a brief section-by-section outline once the bill’s text is available.

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

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