Florida Senate - 2026 SB 1110
By Senator Truenow
13-00237A-26 20261110__
1 A bill to be entitled
2 An act relating to coverage for orthotics and
3 prosthetics services; amending s. 409.906, F.S.;
4 authorizing the Agency for Health Care Administration
5 to authorize and pay for specified orthotics and
6 prosthetics services for Medicaid recipients;
7 requiring the agency to seek federal approval and
8 amend contracts as necessary to implement the act;
9 creating ss. 627.64085, 627.6614, and 641.31079, F.S.;
10 requiring individual health insurance policies; group,
11 blanket, and franchise health insurance policies; and
12 health maintenance contracts, respectively, to provide
13 coverage for specified orthotics and prosthetics
14 services; prohibiting health insurers and health
15 maintenance organizations from denying claims under
16 certain circumstances; requiring health insurers and
17 health maintenance organizations to submit annual
18 reports of specified information to the Office of
19 Insurance Regulation; providing an effective date.
20
21 Be It Enacted by the Legislature of the State of Florida:
22
23 Section 1. Subsection (10) of section 409.906, Florida
24 Statutes, is amended to read:
25 409.906 Optional Medicaid services.—Subject to specific
26 appropriations, the agency may make payments for services which
27 are optional to the state under Title XIX of the Social Security
28 Act and are furnished by Medicaid providers to recipients who
29 are determined to be eligible on the dates on which the services
30 were provided. Any optional service that is provided shall be
31 provided only when medically necessary and in accordance with
32 state and federal law. Optional services rendered by providers
33 in mobile units to Medicaid recipients may be restricted or
34 prohibited by the agency. Nothing in this section shall be
35 construed to prevent or limit the agency from adjusting fees,
36 reimbursement rates, lengths of stay, number of visits, or
37 number of services, or making any other adjustments necessary to
38 comply with the availability of moneys and any limitations or
39 directions provided for in the General Appropriations Act or
40 chapter 216. If necessary to safeguard the state’s systems of
41 providing services to elderly and disabled persons and subject
42 to the notice and review provisions of s. 216.177, the Governor
43 may direct the Agency for Health Care Administration to amend
44 the Medicaid state plan to delete the optional Medicaid service
45 known as “Intermediate Care Facilities for the Developmentally
46 Disabled.” Optional services may include:
47 (10) DURABLE MEDICAL EQUIPMENT.—
48 (a) The agency may authorize and pay for certain durable
49 medical equipment and supplies provided to a Medicaid recipient
50 as medically necessary.
51 (b) The agency may authorize and pay for all of the
52 following orthotics and prosthetics services:
53 1. Orthoses and prostheses as those terms are defined in s.
54 468.80. Coverage must include payment for:
55 a. The model of an orthosis or a prosthesis which is deemed
56 by the recipient’s provider to be the most appropriate to meet
57 the medical needs of the recipient to perform activities of
58 daily living and essential job-related activities; and
59 b. When medically necessary, an orthosis or a prosthesis
60 designed for physical or recreational activities that maximize
61 the recipient’s full body health and lower and upper limb
62 function.
63 2. All materials and components necessary to use the
64 orthosis or prosthesis.
65 3. Instruction on the use of the orthosis or prosthesis.
66 4. Any necessary repairs or replacement of the orthosis or
67 prosthesis.
68 Section 2. The Agency for Health Care Administration shall
69 seek federal approval and amend contracts as necessary to
70 implement the changes made to s. 409.906, Florida Statutes, by
71 this act.
72 Section 3. Section 627.64085, Florida Statutes, is created
73 to read:
74 627.64085 Orthotics and prosthetics services.—
75 (1) A health insurance policy issued, amended, delivered,
76 or renewed in this state on or after July 1, 2026, must provide
77 coverage for all of the following:
78 (a) Orthoses and prostheses as those terms are defined in
79 s. 468.80 if the insured’s provider determines that an orthosis
80 or a prosthesis is medically necessary for the insured to
81 perform activities of daily living, essential job-related
82 activities, and physical recreational activities, such as
83 running, biking, swimming, strength training, and other
84 activities that maximize the insured’s full body health and
85 lower and upper limb function.
86 (b) Any replacement of the orthosis or prosthesis, or part
87 thereof, without regard to continuous use or useful lifetime
88 restrictions, if the insured’s provider determines that it is
89 medically necessary due to any of the following:
90 1. A change in the physiological condition of the insured.
91 2. An irreparable change in the condition of the orthosis
92 or prosthesis, or part thereof.
93 3. A change in the condition of the orthosis or prosthesis,
94 or part thereof, requires repairs that would cost more than 60
95 percent of the cost of a replacement orthosis or prosthesis or
96 of the part thereof requiring replacement.
97
98 A health insurer may require supporting documentation from an
99 insured’s provider to confirm the need for a replacement for an
100 orthosis or a prosthesis that is less than 3 years old.
101 (2) A health insurer may not deny a claim for an orthosis
102 or a prosthesis as a medically necessary intervention to restore
103 physical function for an insured with a disability which would
104 otherwise be covered for a nondisabled person seeking medical or
105 surgical intervention to restore or maintain the ability to
106 perform the same type of physical function affected.
107 (3) Beginning July 1, 2027, and annually thereafter, each
108 health insurer subject to this section shall submit a report to
109 the office detailing the total number of claims submitted for
110 orthotics and prosthetics services in the previous plan year and
111 the total number of such claims that were paid, including the
112 amount paid.
113 Section 4. Section 627.6614, Florida Statutes, is created
114 to read:
115 627.6614 Orthotics and prosthetics services.—
116 (1) A group, blanket, or franchise health insurance policy
117 issued, amended, delivered, or renewed in this state on or after
118 July 1, 2026, must provide coverage for all of the following:
119 (a) Orthoses and prostheses as those terms are defined in
120 s. 468.80 if the insured’s provider determines that an orthosis
121 or a prosthesis is medically necessary for the insured to
122 perform activities of daily living, essential job-related
123 activities, and physical recreational activities, such as
124 running, biking, swimming, strength training, and other
125 activities that maximize the insured’s full body health and
126 lower and upper limb function.
127 (b) Any replacement of the orthosis or prosthesis, or part
128 thereof, without regard to continuous use or useful lifetime
129 restrictions, if the insured’s provider determines that it is
130 medically necessary due to any of the following:
131 1. A change in the physiological condition of the insured.
132 2. An irreparable change in the condition of the orthosis
133 or prosthesis, or part thereof.
134 3. A change in the condition of the orthosis or prosthesis,
135 or part thereof, requires repairs that would cost more than 60
136 percent of the cost of a replacement orthosis or prosthesis or
137 of the part thereof requiring replacement.
138
139 A health insurer may require supporting documentation from an
140 insured’s provider to confirm the need for a replacement for an
141 orthosis or a prosthesis that is less than 3 years old.
142 (2) A health insurer may not deny a claim for an orthosis
143 or a prosthesis as a medically necessary intervention to restore
144 physical function for an insured with a disability which would
145 otherwise be covered for a nondisabled person seeking medical or
146 surgical intervention to restore or maintain the ability to
147 perform the same type of physical function affected.
148 (3) Beginning July 1, 2027, and annually thereafter, each
149 health insurer subject to this section shall submit a report to
150 the office detailing the total number of claims submitted for
151 orthotics and prosthetics services in the previous plan year and
152 the total number of such claims that were paid, including the
153 amount paid.
154 Section 5. Section 641.31079, Florida Statutes, is created
155 to read:
156 641.31079 Orthotics and prosthetics services.—
157 (1) A health maintenance contract issued, amended,
158 delivered, or renewed in this state on or after July 1, 2026,
159 must provide coverage for all of the following:
160 (a) Orthoses and prostheses as those terms are defined in
161 s. 468.80 if the subscriber’s provider determines that an
162 orthosis or a prosthesis is medically necessary for the
163 subscriber to perform activities of daily living, essential job
164 related activities, and physical recreational activities, such
165 as running, biking, swimming, strength training, and other
166 activities that maximize the subscriber’s full body health and
167 lower and upper limb function.
168 (b) Any replacement of the orthosis or prosthesis, or part
169 thereof, without regard to continuous use or useful lifetime
170 restrictions, if the subscriber’s provider determines that it is
171 medically necessary due to any of the following:
172 1. A change in the physiological condition of the
173 subscriber.
174 2. An irreparable change in the condition of the orthosis
175 or prosthesis, or part thereof.
176 3. A change in the condition of the orthosis or prosthesis,
177 or part thereof, requires repairs that would cost more than 60
178 percent of the cost of a replacement orthosis or prosthesis or
179 of the part thereof requiring replacement.
180
181 A health maintenance organization may require supporting
182 documentation from a subscriber’s provider to confirm the need
183 for a replacement for an orthosis or a prosthesis that is less
184 than 3 years old.
185 (2) A health maintenance organization may not deny a claim
186 for an orthosis or a prosthesis as a medically necessary
187 intervention to restore physical function for a subscriber with
188 a disability which would otherwise be covered for a nondisabled
189 person seeking medical or surgical intervention to restore or
190 maintain the ability to perform the same type of physical
191 function affected.
192 (3) Beginning July 1, 2027, and annually thereafter, each
193 health maintenance organization subject to this section shall
194 submit a report to the office detailing the total number of
195 claims submitted for orthotics and prosthetics services in the
196 previous plan year and the total number of such claims that were
197 paid, including the amount paid.
198 Section 6. This act shall take effect July 1, 2026.