SHB 1669
SignedHouse
Prosthetic limb coverage
Concerning coverage requirements for prosthetic limbs and custom orthotic braces.
How does a bill become law?
- Introduced: The bill is filed and assigned a number.
- Committee: A subject-matter committee holds hearings, takes public testimony, and decides whether to advance the bill.
- Floor Vote: The full chamber (House or Senate) debates and votes on the bill.
- Opposite Chamber: The bill repeats the committee and floor vote process in the other chamber.
- Governor: The Governor reviews the bill and decides whether to sign or veto it.
- Signed: The bill has been signed into law.
AI Analysis
This bill requires health insurance plans issued or renewed on or after January 1, 2026 to cover prosthetic limbs and custom orthotic braces when medically necessary for daily activities or physical function, including replacement or repair under specific conditions—regardless of device age—while ensuring parity with federal Medicare coverage standards. It also mandates reporting of claims data to the state Insurance Commissioner.
- Starting January 1, 2026, all new or renewed health plans must cover one or more prosthetic limbs and custom orthotic braces per limb when medically necessary for daily living, work, or physical activities like running or swimming.
- Coverage must include materials, components, instruction on use, and reasonable repair or replacement of devices.
- Devices (or parts) must be replaced or repaired without regard to age or continuous use, if medically necessary due to changes in the patient’s condition, device damage, or if repairs would cost more than 60% of a replacement cost.
- Insurers may require written confirmation from a prescriber if the device or part is less than three years old at time of replacement/repair.
- Plans cannot deny coverage for a prosthetic or orthotic device if similar services would be covered for a non-disabled person seeking the same functional improvement.
- Insurers must report claims data (number and total cost) to the Office of the Insurance Commissioner by July 1, 2028, for plan years 2026 and 2027, and the Commissioner must submit a summary report to the legislature by December 1, 2028.
Who is affected
- People with disabilities or mobility impairments — People with disabilities or mobility-impairing conditions who need prosthetic limbs or custom orthotic braces to perform daily activities or physical tasks will gain stronger insurance coverage protections and more consistent access to needed devices and services.
- Health insurance carriers (private insurers, public plan sponsors) — Health insurance companies issuing new or renewed plans on or after January 1, 2026, must expand coverage to include prosthetic limbs and custom orthotic braces under specific conditions, and must report claims data starting in 2028.
- State employees and retirees — State employees and retirees enrolled in state-administered health plans (e.g., Washington State Health Benefit Exchange plans, Public Employees Benefits Board plans) will be covered under the new requirements.
- Health care providers and device specialists — Prescribers (e.g., physicians, physical therapists, orthotists) may be asked to confirm medical necessity for replacements or repairs of devices less than three years old.
Pro/Con Analysis
Stronger case for benefits
Potential Benefits (5)
Prohibits insurers from denying coverage for prosthetic/orthotic devices if similar services would be covered for a nondisabled person—effectively banning disability-based coverage discrimination and affirming equal access to functional improvement, a significant civil rights advance for people with disabilities.
Rights & LibertiesPeopleRef: Sec. 1(4)Requires coverage for repairs when cost exceeds 60% of replacement cost—regardless of device age—preventing insurers from imposing arbitrary age-based denials and ensuring continuity of care for patients whose devices degrade or fail unexpectedly.
HealthcarePeopleRef: Sec. 1(3)(a)(iii)Explicitly includes coverage for physical activities like running, biking, swimming, and strength training—not just basic mobility—expanding access to high-functionality devices that enable full participation in work, education, and community life, especially for younger and working-age adults with limb loss.
HealthcarePeopleRef: Sec. 1(1)(b)Mandates coverage for instruction on device use, reducing the burden on patients and families to self-train and improving long-term functional outcomes—particularly valuable for elderly or cognitively impaired users who rely on professional guidance.
HealthcarePeopleRef: Sec. 1(2)(c)Requires claims data reporting to the Office of the Insurance Commissioner, enabling evidence-based oversight and future policy adjustments—this transparency helps prevent insurer gaming of the system and supports equitable resource allocation.
Public SafetyPeopleRef: Sec. 1(7)
Potential Concerns (5)
Requires prescriber confirmation for replacement/repair of devices less than three years old, which may create administrative barriers and delays for patients—particularly those with rapidly changing medical needs—without clear clinical justification, potentially increasing out-of-pocket time and coordination burden.
HealthcareLean industryRef: Sec. 1(3)(b)Allows insurers to apply standard utilization management and prior authorization for prosthetic/orthotic coverage, which may lead to coverage denials or delays—especially for lower-income or less-resourced patients who lack advocacy support—despite the mandate for parity with Medicare.
HealthcareIndustryRef: Sec. 1(5)Ties coverage levels to Medicare payment standards, which are known to underpay providers relative to commercial rates, potentially reducing provider participation and access to high-quality prosthetic specialists—especially in rural or underserved areas of Washington.
HealthcareIndustryRef: Sec. 1(6)Expands insurer administrative and actuarial responsibilities (e.g., coverage design, claims processing, reporting), which may increase premiums for small-group and individual market plans—particularly those with limited risk-pooling capacity—though the fiscal impact estimate is unspecified.
Business & EmploymentLean industryRef: Sec. 1(1)–(2)Mandates parity with Medicare coverage standards, but Medicare’s prosthetic coverage is famously fragmented and underfunded—e.g., it covers only one prosthesis per limb with strict functional criteria and limited repair/replacement provisions—so the bill may codify inadequate baseline coverage rather than raise the bar.
HealthcareIndustryRef: Sec. 1(6)
Who Is Most Affected
People with limb loss or mobility impairments—especially those on fixed incomes, young adults, and older adults—will gain more reliable access to essential devices and repairs, reducing out-of-pocket costs and functional decline. However, those in rural areas may still face access barriers due to provider shortages.
Private insurers will face higher claims costs and administrative burdens, but the impact is mitigated by the 60% repair-cost threshold and utilization management tools. Large, diversified insurers are better positioned than small carriers, potentially accelerating market consolidation.
State employees and retirees benefit from automatic inclusion under state-administered plans, but if state plans were previously more generous than Medicare parity, they may face cost-containment adjustments over time.
Prescribers and orthotists gain clearer coverage guidelines and may see increased demand, but the requirement for prescriber confirmation for devices <3 years old adds documentation burden without additional compensation, and Medicare-level payments may constrain provider participation.