Florida Senate - 2026 CS for SB 1110
By the Committee on Banking and Insurance; and Senators Truenow
and Smith
597-02756-26 20261110c1
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 defining the term “eligible individual”; authorizing
5 the Agency for Health Care Administration to authorize
6 and pay for specified orthotics and prosthetics
7 services for Medicaid recipients who are eligible
8 individuals; providing construction; requiring the
9 agency to seek federal approval and amend contracts as
10 necessary to implement the act; creating ss.
11 627.64085, 627.6614, and 641.31079, F.S.; defining the
12 term “eligible individual”; requiring individual
13 health insurance policies; group, blanket, and
14 franchise health insurance policies; and health
15 maintenance contracts, respectively, to provide
16 coverage for specified orthotics and prosthetics
17 services for eligible individuals; authorizing health
18 insurers and health maintenance organizations to
19 require certain supporting documentation; prohibiting
20 health insurers and health maintenance organizations
21 from denying claims under certain circumstances;
22 requiring health insurers and health maintenance
23 organizations to submit annual reports of specified
24 information to the Office of Insurance Regulation;
25 providing construction; providing an effective date.
26
27 Be It Enacted by the Legislature of the State of Florida:
28
29 Section 1. Subsection (10) of section 409.906, Florida
30 Statutes, is amended to read:
31 409.906 Optional Medicaid services.—Subject to specific
32 appropriations, the agency may make payments for services which
33 are optional to the state under Title XIX of the Social Security
34 Act and are furnished by Medicaid providers to recipients who
35 are determined to be eligible on the dates on which the services
36 were provided. Any optional service that is provided shall be
37 provided only when medically necessary and in accordance with
38 state and federal law. Optional services rendered by providers
39 in mobile units to Medicaid recipients may be restricted or
40 prohibited by the agency. Nothing in this section shall be
41 construed to prevent or limit the agency from adjusting fees,
42 reimbursement rates, lengths of stay, number of visits, or
43 number of services, or making any other adjustments necessary to
44 comply with the availability of moneys and any limitations or
45 directions provided for in the General Appropriations Act or
46 chapter 216. If necessary to safeguard the state’s systems of
47 providing services to elderly and disabled persons and subject
48 to the notice and review provisions of s. 216.177, the Governor
49 may direct the Agency for Health Care Administration to amend
50 the Medicaid state plan to delete the optional Medicaid service
51 known as “Intermediate Care Facilities for the Developmentally
52 Disabled.” Optional services may include:
53 (10) DURABLE MEDICAL EQUIPMENT.—
54 (a) The agency may authorize and pay for certain durable
55 medical equipment and supplies provided to a Medicaid recipient
56 as medically necessary.
57 (b)1. As used in this paragraph, the term “eligible
58 individual” means a Medicaid recipient who is:
59 a. A child younger than 18 years of age;
60 b. A dependent child as specified in s. 627.6562;
61 c. An individual 26 years of age or younger who remains
62 covered under a parent’s health insurance policy pursuant to s.
63 627.6562; or
64 d. An individual with a developmental disability as defined
65 in s. 393.063.
66 2. The agency may authorize and pay for all of the
67 following orthotics and prosthetics services for eligible
68 individuals:
69 a. Orthoses and prostheses as those terms are defined in s.
70 468.80. Coverage must include payment for:
71 (I) The model of an orthosis or a prosthesis which is
72 deemed by the eligible individual’s provider to be the most
73 appropriate to meet the medical needs of the eligible individual
74 to perform activities of daily living and essential job-related
75 activities; and
76 (II) When medically necessary, an orthosis or a prosthesis
77 designed for physical or recreational activities that maximize
78 the eligible individual’s full body health and lower and upper
79 limb function.
80 b. All materials and components necessary to use the
81 orthosis or prosthesis.
82 c. Instruction on the use of the orthosis or prosthesis.
83 d. Any necessary repairs or replacement of the orthosis or
84 prosthesis.
85 3. This paragraph may not be construed to require Medicaid
86 coverage of orthotics and prosthetics services specified herein
87 for a Medicaid recipient who is not an eligible individual.
88 Section 2. The Agency for Health Care Administration shall
89 seek federal approval and amend contracts as necessary to
90 implement the changes made to s. 409.906, Florida Statutes, by
91 this act.
92 Section 3. Section 627.64085, Florida Statutes, is created
93 to read:
94 627.64085 Orthotics and prosthetics services.—
95 (1) As used in this section, the term “eligible individual”
96 means an insured who is:
97 a. A child younger than 18 years of age;
98 b. A dependent child as specified in s. 627.6562;
99 c. An individual 26 years of age or younger who remains
100 covered under a parent’s health insurance policy pursuant to s.
101 627.6562; or
102 d. An individual with a developmental disability as defined
103 in s. 393.063.
104 (2) A health insurance policy issued, amended, delivered,
105 or renewed in this state on or after July 1, 2026, must provide
106 coverage of all of the following for eligible individuals:
107 (a) Orthoses and prostheses as those terms are defined in
108 s. 468.80 if the eligible individual’s provider determines that
109 an orthosis or a prosthesis is medically necessary for the
110 eligible individual to perform activities of daily living,
111 essential job-related activities, and physical recreational
112 activities, such as running, biking, swimming, strength
113 training, and other activities that maximize the eligible
114 individual’s full body health and lower and upper limb function.
115 (b) Any replacement of the orthosis or prosthesis, or part
116 thereof, without regard to continuous use or useful lifetime
117 restrictions, if the eligible individual’s provider determines
118 that it is medically necessary due to any of the following:
119 1. A change in the physiological condition of the eligible
120 individual.
121 2. An irreparable change in the condition of the orthosis
122 or prosthesis, or part thereof.
123 3. A change in the condition of the orthosis or prosthesis,
124 or part thereof, requires repairs that would cost more than 60
125 percent of the cost of a replacement orthosis or prosthesis or
126 of the part thereof requiring replacement.
127
128 A health insurer may require supporting documentation from an
129 eligible individual’s provider to confirm the need for a
130 replacement for an orthosis or a prosthesis that is less than 3
131 years old.
132 (3) A health insurer may not deny a claim for an orthosis
133 or a prosthesis as a medically necessary intervention to restore
134 physical function for an eligible individual with a disability
135 which would otherwise be covered for a nondisabled person
136 seeking medical or surgical intervention to restore or maintain
137 the ability to perform the same type of physical function
138 affected.
139 (4) Beginning July 1, 2027, and annually thereafter, each
140 health insurer subject to this section shall submit a report to
141 the Office of Insurance Regulation detailing the total number of
142 claims submitted for orthotics and prosthetics services in the
143 previous plan year and the total number of such claims that were
144 paid, including the amount paid.
145 (5) This section may not be construed to require coverage
146 of orthotics or prosthetics services for an insured who is not
147 an eligible individual.
148 Section 4. Section 627.6614, Florida Statutes, is created
149 to read:
150 627.6614 Orthotics and prosthetics services.—
151 (1) As used in this section, the term “eligible individual”
152 means an insured who is:
153 a. A child younger than 18 years of age;
154 b. A dependent child as specified in s. 627.6562;
155 c. An individual 26 years of age or younger who remains
156 covered under a parent’s health insurance policy pursuant to s.
157 627.6562; or
158 d. An individual with a developmental disability as defined
159 in s. 393.063.
160 (2) A group, blanket, or franchise health insurance policy
161 issued, amended, delivered, or renewed in this state on or after
162 July 1, 2026, must provide coverage of all of the following for
163 eligible individuals:
164 (a) Orthoses and prostheses as those terms are defined in
165 s. 468.80 if the eligible individual’s provider determines that
166 an orthosis or a prosthesis is medically necessary for the
167 eligible individual to perform activities of daily living,
168 essential job-related activities, and physical recreational
169 activities, such as running, biking, swimming, strength
170 training, and other activities that maximize the eligible
171 individual’s full body health and lower and upper limb function.
172 (b) Any replacement of the orthosis or prosthesis, or part
173 thereof, without regard to continuous use or useful lifetime
174 restrictions, if the eligible individual’s provider determines
175 that it is medically necessary due to any of the following:
176 1. A change in the physiological condition of the eligible
177 individual.
178 2. An irreparable change in the condition of the orthosis
179 or prosthesis, or part thereof.
180 3. A change in the condition of the orthosis or prosthesis,
181 or part thereof, requires repairs that would cost more than 60
182 percent of the cost of a replacement orthosis or prosthesis or
183 of the part thereof requiring replacement.
184
185 A health insurer may require supporting documentation from an
186 eligible individual’s provider to confirm the need for a
187 replacement for an orthosis or a prosthesis that is less than 3
188 years old.
189 (3) A health insurer may not deny a claim for an orthosis
190 or a prosthesis as a medically necessary intervention to restore
191 physical function for an eligible individual with a disability
192 which would otherwise be covered for a nondisabled person
193 seeking medical or surgical intervention to restore or maintain
194 the ability to perform the same type of physical function
195 affected.
196 (4) Beginning July 1, 2027, and annually thereafter, each
197 health insurer subject to this section shall submit a report to
198 the Office of Insurance Regulation detailing the total number of
199 claims submitted for orthotics and prosthetics services in the
200 previous plan year and the total number of such claims that were
201 paid, including the amount paid.
202 (5) This section may not be construed to require coverage
203 of orthotics or prosthetics services for an insured who is not
204 an eligible individual.
205 Section 5. Section 641.31079, Florida Statutes, is created
206 to read:
207 641.31079 Orthotics and prosthetics services.—
208 (1) As used in this section, the term “eligible individual”
209 means a subscriber who is:
210 a. A child younger than 18 years of age;
211 b. A dependent child as specified in s. 627.6562;
212 c. An individual 26 years of age or younger who remains
213 covered under a parent’s health insurance policy pursuant to s.
214 627.6562; or
215 d. An individual with a developmental disability as defined
216 in s. 393.063.
217 (2) A health maintenance contract issued, amended,
218 delivered, or renewed in this state on or after July 1, 2026,
219 must provide coverage of all of the following for eligible
220 individuals:
221 (a) Orthoses and prostheses as those terms are defined in
222 s. 468.80 if the eligible individual’s provider determines that
223 an orthosis or a prosthesis is medically necessary for the
224 eligible individual to perform activities of daily living,
225 essential job-related activities, and physical recreational
226 activities, such as running, biking, swimming, strength
227 training, and other activities that maximize the eligible
228 individual’s full body health and lower and upper limb function.
229 (b) Any replacement of the orthosis or prosthesis, or part
230 thereof, without regard to continuous use or useful lifetime
231 restrictions, if the subscriber’s provider determines that it is
232 medically necessary due to any of the following:
233 1. A change in the physiological condition of the eligible
234 individual.
235 2. An irreparable change in the condition of the orthosis
236 or prosthesis, or part thereof.
237 3. A change in the condition of the orthosis or prosthesis,
238 or part thereof, requires repairs that would cost more than 60
239 percent of the cost of a replacement orthosis or prosthesis or
240 of the part thereof requiring replacement.
241
242 A health maintenance organization may require supporting
243 documentation from an eligible individual’s provider to confirm
244 the need for a replacement for an orthosis or a prosthesis that
245 is less than 3 years old.
246 (3) A health maintenance organization may not deny a claim
247 for an orthosis or a prosthesis as a medically necessary
248 intervention to restore physical function for an eligible
249 individual with a disability which would otherwise be covered
250 for a nondisabled person seeking medical or surgical
251 intervention to restore or maintain the ability to perform the
252 same type of physical function affected.
253 (4) Beginning July 1, 2027, and annually thereafter, each
254 health maintenance organization subject to this section shall
255 submit a report to the Office of Insurance Regulation detailing
256 the total number of claims submitted for orthotics and
257 prosthetics services in the previous plan year and the total
258 number of such claims that were paid, including the amount paid.
259 (5) This section may not be construed to require coverage
260 of orthotics or prosthetics services for a subscriber who is not
261 an eligible individual.
262 Section 6. This act shall take effect July 1, 2026.