(1) Except as provided in subsection (9) of this section, a health plan offered in the large group or small group market that is issued or renewed on or after January 1, 2026, must include coverage for one or more prostheses per limb and custom orthotic braces per limb when medically necessary for the enrollee to participate in any of the following:
(a) Completing activities of daily living or essential job-related activities; and
(b) Performing physical activities, including but not limited to running, biking, swimming, and strength training, for maximizing the enrollee's lower limb function, upper limb function, or both.
(2) The coverage required under this section must also include coverage for:
(a) Materials, components, and related services necessary to use the devices for their intended purposes;
(b) Instruction to the enrollee on using the devices; and
(c) Reasonable repair or replacement of the devices.
(3)(a) Coverage under this section includes coverage for the replacement or repair of a prosthetic limb or custom orthotic brace or for the replacement or repair of any part of such devices, without regard to continuous use or useful lifetime restrictions, if medically necessary because:
(i) Of a change in the physiological condition of the patient;
(ii) Of an irreparable change in the condition of the device or a part of the device; or
(iii) The device, or any part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device or of the part being replaced.
(b) Confirmation from the prescribing health care provider may be required if the prosthetic limb or custom orthotic brace or part being replaced is less than three years old.
(4) A health plan offered in the large group or small group market may not deny coverage for a prosthetic limb or custom orthotic brace for an enrollee with a disability if health care services 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.
(5) For coverage under this section, a health plan offered in the large group or small group market may apply normal utilization management and prior authorization practices. Any denial of coverage must be issued in writing with an explanation for determining coverage was not medically necessary.
(6) A health plan offered in the large group or small group market shall provide payment for coverage under this section that is at least equal to the payment and coverage for prosthetic limbs and custom orthotic braces provided under federal laws and regulations for the aged and disabled pursuant to 42 U.S.C. Sec. 1395k, 1395l, and 1395m and 42 C.F.R. Sec. 414.202, 414.210, 414.228, and 410.100.
(7) No later than July 1, 2028, each carrier that issues a health plan subject to this section shall report to the office of the insurance commissioner, in a form and manner determined by the commissioner, the number of claims and the total amount of claims paid in the state for the services required by this section for plan years 2026 and 2027. The commissioner shall aggregate this data by plan year in a report and submit the report to the relevant committees of the legislature by December 1, 2028.
(8) For the purposes of this section:
(a) "Prosthetic limb" or "prosthesis" means an external medical device that is used to replace or restore a missing limb or portion of a limb and is deemed medically necessary for an individual with a mobility impairing health condition or disability.
(b) "Custom orthotic brace" means an external medical device that is custom-fabricated or custom-fitted to support, correct, or alleviate neuromuscular or musculoskeletal dysfunction, disease, injury, or deformity, is needed to improve the safety and efficiency of functional mobility, is patient-specific based on the patient's unique physical condition, and is deemed medically necessary for individuals with a mobility impairing health condition or disability.
(9) This section does not apply to health plans offered in the individual market or to self-insured or fully insured large group health plans offered to public employees and school employees under chapter
41.05 RCW.
