25 LC 60 0167S
Senate Bill 101
By: Senators Robertson of the 29th, Hatchett of the 50th, Payne of the 54th, Williams of the
25th, Still of the 48th and others
AS PASSED
A BILL TO BE ENTITLED
AN ACT
To amend Title 33 of the Official Code of Georgia Annotated, relating to insurance, so as to
1
require certain health benefit policy coverage for medically necessary orthotic devices and2
prosthetic devices and their materials and components; to provide for definitions; to provide3
for requirements; to provide for reporting; to provide for rules and regulations; to provide for4
related matters; to provide for an effective date; to repeal conflicting laws; and for other5
purposes.6
BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:7
SECTION 1.8
Title 33 of the Official Code of Georgia Annotated, relating to insurance, is amended in9
Chapter 24, relating to insurance generally, by adding a new Code section to read as follows:10
"33-24-59.34.
11
(a) As used in this Code section, the term:12
(1) 'Cost-sharing requirement' shall have the same meaning as set forth in Code13
Section 33-24-59.32.14
(2) 'Covered person' means an individual covered under a health benefit policy.15
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(3) 'Health benefit policy' means any individual or group plan, policy, or contract for16
healthcare services issued, delivered, issued for delivery, or renewed in this state by an17
insurer that provides major medical benefits. Such term shall not include any plans,18
policies, or contracts executed by the state on behalf of state employees under Article 119
of Chapter 18 of Title 45 and shall not apply to the provision of healthcare services20
pursuant to a contract entered into by an insurer and the Department of Community21
Health for recipients of Medicaid. Such term shall not include self-funded, employer22
sponsored health insurance plans subject to the exclusive jurisdiction of the federal23
Employee Retirement Income Security Act of 1974, as codified and amended at 2924
U.S.C. Section 1001, et seq.25
(4) 'Health insurer' means any person, corporation, or other entity authorized to provide26
health benefit policies under this title.27
(5) 'Medically necessary' shall have the same meaning as set forth in Code28
Section 33-46-4 and shall be in accordance with nationally recognized clinical practice29
guidelines.30
(6) 'Nationally recognized clinical practice guidelines' means evidence based clinical31
practice guidelines developed by independent organizations or medical professional32
societies utilizing a transparent methodology and reporting structure and with a conflict33
of interest policy. Such guidelines establish standards of care informed by a systematic34
review of evidence and an assessment of the benefits and risks of alternative care options35
and include recommendations intended to optimize patient care.36
(7) 'Orthotic device' or 'orthosis' means a custom fabricated or custom fitted device that37
is designed, fabricated, modified, or fitted to correct, support, or compensate for a38
neuromusculoskeletal disorder or acquired condition for the purpose of stabilizing,39
stretching, or immobilizing a body part, improving alignment, preventing deformities,40
protecting against injury, or assisting with motion or function, and is worn on the outside41
of the body to help with such structural or functional problems. Such term does not42
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include fabric or elastic supports, corsets, arch supports, low-temperature plastic splints,43
trusses, elastic hoses, canes, crutches, soft cervical collars, dental appliances, or other44
similar devices that are carried in stock and sold as over-the-counter items by a drug45
store, department store, corset shop, or surgical supply facility.46
(8) 'Prosthetic device' or 'prosthesis' means a custom designed, fabricated, fitted,47
modified, or fitted and modified device to replace an absent external body part for48
purposes of restoring physiological function or cosmesis or both. Such term does not49
include artificial eyes or ears; dental appliances; cosmetic devices such as artificial50
breasts, eyelashes, or wigs; or other devices that do not have a significant impact on51
mobility or the musculoskeletal functions of the body.52
(b) All health benefit policies renewed or issued on or after January 1, 2026, shall include53
coverage for orthotic devices and prosthetic devices that are medically necessary for:54
(1) Activities of daily living;55
(2) Essential job related activities;56
(3) Personal hygiene related activities, including, but not limited to, showering, bathing,57
and toileting; or58
(4) Physical activities, including, but not limited to, running, biking, swimming, and59
strength training, so as to maximize the covered person's whole body health and both60
upper and lower limb function.61
(c) The coverage provided for in this Code section shall include no more than three62
orthotic devices or prosthetic devices per affected limb per covered person during any63
three-year period. Such coverage shall include:64
(1) All materials and components for the use of the orthotic device or prosthetic device,65
including:66
(A) The orthosis or prosthesis;67
(B) Structural components such as the socket;68
(C) Suspension mechanisms such as the pin, lock, suction, and elevated vacuum;69
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(D) Hip joint, knee joint, foot, alignable parts, and terminal device;70
(E) Connective components such as pads, bands, and cushions; and71
(F) Consumable items such as socks, sleeves, and liners;72
(2) Formulation of the device's design, fabrication, measurements and fittings;73
(3) Education and training on using and maintaining such device; and74
(4) The repair of such device and its components.75
(d)(1) The replacement of an orthotic device or prosthetic device and its materials and76
components when such device is less than three years old shall be medically necessary77
if there is adequate documentation of a change in the physiological condition of the78
covered person, an irreparable change in the condition of the device or any of its79
components, or the condition of the device or a component of the device requires repairs80
and the cost of such repairs would be more than 60 percent of the cost of the device.81
(2) A socket replacement shall be medically necessary if there is adequate documentation82
of a physiological need, including, but not limited to, a change in the residual limb, a83
functional need change, irreparable damage, or wear and tear due to excessive weight of84
a covered person or physical demands of an active covered person.85
(e) A health insurer shall not be required to replace or repair an orthotic device or86
prosthetic device due to misuse, malicious damage, gross neglect, loss, or theft.87
(f) The coverage provided for in this Code section:88
(1) Shall be considered as habilitative or rehabilitative benefits for purposes of any state89
or federal requirements for coverage of essential health benefits;90
(2) Shall be comparable to coverage for other medical and surgical benefits under the91
health benefit policy, including restorative internal devices;92
(3) May be subject to the same cost-sharing requirements that apply to other medical93
devices and services covered by the health benefit policy; provided, however, that such94
requirements shall not be solely applicable to such coverage; and95
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(4) May be limited, or the cost-sharing requirements for such coverage may be altered96
for out-of-network providers; provided, however, that any limitations shall not be more97
restrictive than the restrictions and requirements applicable to the out-of-network98
coverage for the policy's medical or surgical coverage.99
(g) Nothing in this Code section shall be construed to prohibit a health insurer from issuing100
or renewing a health benefit policy which provides benefits greater than the minimum101
benefits required under this Code section or from issuing or renewing a policy which102
provides benefits which are generally more favorable to the covered person than those103
required under this Code section.104
(h) By July 1, 2032, the Commissioner shall submit a report to the House Committee on105
Insurance and the Senate Insurance and Labor Committee regarding the implementation106
of the coverage required under this Code section. All health insurers issuing or renewing107
health benefit policies subject to the provisions of this Code section shall provide the108
department with all data requested by the department for inclusion in such report,109
including, but limited to, the total number of claims submitted, the total number of claims110
paid, and the total amount of claims paid for the coverage provided for by this Code section111
for policy years from 2026 to 2030.112
(i) The Commissioner shall promulgate rules and regulations necessary to implement the113
provisions of this Code section."114
SECTION 2.115
This Act shall become effective upon its approval by the Governor or upon its becoming law116
without such approval.117
SECTION 3.118
All laws and parts of laws in conflict with this Act are repealed.119
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