SB100 Summary

• Health benefit plans must provide coverage for custom prosthetic and orthotic devices at least equivalent to Medicare's coverage and no less favorable than medical and surgical benefits.

• Coverage must include the most appropriate devices deemed medically necessary by the treating physician, along with all services and supplies necessary for effective device use, including design, fabrication, fitting, and patient instruction.

• Reimbursement rates for prosthetic and orthotic devices must match Medicare rates and cannot be more restrictive than other plan benefits; plans may impose copayments or coinsurance but not separate financial requirements unique to these devices.

• Plans cannot impose annual or lifetime dollar maximums on prosthetic and orthotic device coverage except those applying to all covered services; managed care plans must provide access to at least two distinct prosthetic and orthotic device providers in-network.

• The requirement applies to health care service plans and health maintenance organizations beginning October 1, 2019, and excludes certain limited benefit plans and the Alabama Health Insurance Plan.