Pennsylvania HB 1391: An Act amending the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, in casualty insurance, providing for reimbursement for custom-fabricated devices, custom-fitted devices, orthosis, orthotics, over-the-counter prostheses, orthoses and pedorthic devices, prefabricated orthoses, prostheses, prosthetics and components of such devices.

Bill Text

PRINTER'S NO. 1586
THE GENERAL ASSEMBLY OF PENNSYLVANIA
HOUSE BILL
No. 1391
Session of
2025
INTRODUCED BY GAYDOS, HANBIDGE, GALLAGHER AND BOROWSKI,
MAY 5, 2025
REFERRED TO COMMITTEE ON INSURANCE, MAY 5, 2025
AN ACT
Amending the act of May 17, 1921 (P.L.682, No.284), entitled "An
act relating to insurance; amending, revising, and
consolidating the law providing for the incorporation of
insurance companies, and the regulation, supervision, and
protection of home and foreign insurance companies, Lloyds
associations, reciprocal and inter-insurance exchanges, and
fire insurance rating bureaus, and the regulation and
supervision of insurance carried by such companies,
associations, and exchanges, including insurance carried by
the State Workmen's Insurance Fund; providing penalties; and
repealing existing laws," in casualty insurance, providing
for reimbursement for custom-fabricated devices, custom-
fitted devices, orthosis, orthotics, over-the-counter
prostheses, orthoses and pedorthic devices, prefabricated
orthoses, prostheses, prosthetics and components of such
devices.
The General Assembly of the Commonwealth of Pennsylvania
hereby enacts as follows:
Section 1. The act of May 17, 1921 (P.L.682, No.284), known
as The Insurance Company Law of 1921, is amended by adding a
section to read:
Section 635.11. Reimbursement for Custom-Fabricated Devices,
Custom-Fitted Devices, Orthosis, Orthotics, Over-the-Counter
Prostheses, Orthoses and Pedorthic Devices, Prefabricated
Orthoses, Prostheses, Prosthetics and Components of Such
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Devices.--(a) Except to the extent coverage is provided under
another policy, an individual or group health, sickness and
accident insurance policy, group health insurance plan or policy
or any other form of a managed or capitated care plan, policy,
subscriber contract or certificate, issued by an insurer subject
to 40 Pa.C.S. Ch. 61 (relating to hospital plan corporations) or
63 (relating to professional health services plan corporations),
the act of December 29, 1972 (P.L.1701, No.364), known as the
"Health Maintenance Organization Act," or this act, which
provides hospital or medical and surgical coverage, shall
provide coverage for custom-fabricated devices, custom-fitted
devices, orthosis, orthotics, over-the-counter prostheses,
orthoses and pedorthic devices, prefabricated orthoses,
prostheses, prosthetics and components of such devices, when
prescribed by a physician, podiatrist, certified registered
nurse practitioner or physician assistant legally authorized to
issue the prescription. Prior to the initial prosthetic,
orthotic, pedorthic or orthotic fitting authorized under this
section, a prosthetist, orthotist, pedorthist or orthotics
fitter shall have the following duties:
(1) Ensure that the patient has obtained a prescription,
accompanied by clinical notes for treatment, from a physician,
podiatrist, certified registered nurse practitioner or physician
assistant. The prescription may impose conditions and
restrictions on the course of treatment as required by sound
medical practice.
(2) Verify that the patient has undergone a medical
diagnostic examination or that the results of a recently
performed medical diagnostic examination have been reviewed by a
physician, podiatrist, certified registered nurse practitioner,
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or physician assistant.
(3) Retain in the patient's file a copy of the prescription
and the results of the medical diagnostic examination.
(b) The benefits specified under this section may be
provided through a combination of policies, contracts,
certificates or riders, including major medical contracts, and
shall be recognized within this Commonwealth.
(c) The following shall apply:
(1) An insurer may require preauthorization to determine the
medical necessity and eligibility of benefits for custom-
fabricated devices, custom-fitted devices, orthosis, orthotics,
over-the-counter prostheses, orthoses and pedorthic devices,
prefabricated orthoses, prostheses, prosthetics and components
of such devices.
(2) Coverage under this section shall extend to the fitting,
repair or replacement of custom-fabricated devices, custom-
fitted devices, orthosis, orthotics, over-the-counter
prostheses, orthoses and pedorthic devices, prefabricated
orthoses, prostheses, prosthetics and components of such
devices, when the fitting, repair or replacement is deemed
medically necessary. Coverage under this section shall not be
provided for the fitting, repair or replacement necessitated by
negligence in proper care and maintenance or by an abusive act
committed by the individual utilizing such devices or
components.
(3) An insurer shall require that custom-fabricated devices,
custom-fitted devices, orthosis, orthotics, over-the-counter
prostheses, orthoses and pedorthic devices, prefabricated
orthoses, prostheses, prosthe