Georgia 2025-2026 Regular Session

Georgia Senate Bill SB101 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		25 LC 60 0167S
2		-	Senate Bill 101
3		-	By: Senators Robertson of the 29th, Hatchett of the 50th, Payne of the 54th, Williams of the
4		-	25th, Still of the 48th and others
5		-	AS PASSED
	2	+	The House Committee on Public and Community Health offers the following substitute
	3	+	to SB 101:
6	4		A BILL TO BE ENTITLED
7	5		AN ACT
8		-	To amend Title 33 of the Official Code of Georgia Annotated, relating to insurance, so as to
9		-	1
	6	+	To amend Title 33 of the Official Code of Georgia Annotated, relating to insurance, so as to1
10	7		require certain health benefit policy coverage for medically necessary orthotic devices and2
11	8		prosthetic devices and their materials and components; to provide for definitions; to provide3
12	9		for requirements; to provide for reporting; to provide for rules and regulations; to provide for4
13	10		related matters; to provide for an effective date; to repeal conflicting laws; and for other5
14	11		purposes.6
15	12		BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:7
16	13		SECTION 1.8
17	14		Title 33 of the Official Code of Georgia Annotated, relating to insurance, is amended in9
18	15		Chapter 24, relating to insurance generally, by adding a new Code section to read as follows:10
19		-	"33-24-59.34.
20		-	11
	16	+	"33-24-59.34.11
21	17		(a) As used in this Code section, the term:12
22	18		(1) 'Cost-sharing requirement' shall have the same meaning as set forth in Code13
23	19		Section 33-24-59.32.14
24	20		(2) 'Covered person' means an individual covered under a health benefit policy.15
25		-	S. B. 101
	21	+	S. B. 101 (SUB)
26	22		- 1 - 25 LC 60 0167S
27	23		(3) 'Health benefit policy' means any individual or group plan, policy, or contract for16
28	24		healthcare services issued, delivered, issued for delivery, or renewed in this state by an17
29	25		insurer that provides major medical benefits. Such term shall not include any plans,18
30	26		policies, or contracts executed by the state on behalf of state employees under Article 119
31	27		of Chapter 18 of Title 45 and shall not apply to the provision of healthcare services20
32	28		pursuant to a contract entered into by an insurer and the Department of Community21
33	29		Health for recipients of Medicaid. Such term shall not include self-funded, employer22
34	30		sponsored health insurance plans subject to the exclusive jurisdiction of the federal23
35	31		Employee Retirement Income Security Act of 1974, as codified and amended at 2924
36	32		U.S.C. Section 1001, et seq.25
37	33		(4) 'Health insurer' means any person, corporation, or other entity authorized to provide26
38	34		health benefit policies under this title.27
39	35		(5) 'Medically necessary' shall have the same meaning as set forth in Code28
40	36		Section 33-46-4 and shall be in accordance with nationally recognized clinical practice29
41	37		guidelines.30
42	38		(6) 'Nationally recognized clinical practice guidelines' means evidence based clinical31
43	39		practice guidelines developed by independent organizations or medical professional32
44	40		societies utilizing a transparent methodology and reporting structure and with a conflict33
45	41		of interest policy. Such guidelines establish standards of care informed by a systematic34
46	42		review of evidence and an assessment of the benefits and risks of alternative care options35
47	43		and include recommendations intended to optimize patient care.36
48	44		(7) 'Orthotic device' or 'orthosis' means a custom fabricated or custom fitted device that37
49	45		is designed, fabricated, modified, or fitted to correct, support, or compensate for a38
50	46		neuromusculoskeletal disorder or acquired condition for the purpose of stabilizing,39
51	47		stretching, or immobilizing a body part, improving alignment, preventing deformities,40
52	48		protecting against injury, or assisting with motion or function, and is worn on the outside41
53	49		of the body to help with such structural or functional problems. Such term does not42
54		-	S. B. 101
	50	+	S. B. 101 (SUB)
55	51		- 2 - 25 LC 60 0167S
56	52		include fabric or elastic supports, corsets, arch supports, low-temperature plastic splints,43
57	53		trusses, elastic hoses, canes, crutches, soft cervical collars, dental appliances, or other44
58	54		similar devices that are carried in stock and sold as over-the-counter items by a drug45
59	55		store, department store, corset shop, or surgical supply facility.46
60	56		(8) 'Prosthetic device' or 'prosthesis' means a custom designed, fabricated, fitted,47
61	57		modified, or fitted and modified device to replace an absent external body part for48
62	58		purposes of restoring physiological function or cosmesis or both. Such term does not49
63	59		include artificial eyes or ears; dental appliances; cosmetic devices such as artificial50
64	60		breasts, eyelashes, or wigs; or other devices that do not have a significant impact on51
65	61		mobility or the musculoskeletal functions of the body.52
66	62		(b) All health benefit policies renewed or issued on or after January 1, 2026, shall include53
67	63		coverage for orthotic devices and prosthetic devices that are medically necessary for:54
68	64		(1) Activities of daily living;55
69	65		(2) Essential job related activities;56
70	66		(3) Personal hygiene related activities, including, but not limited to, showering, bathing,57
71	67		and toileting; or58
72	68		(4) Physical activities, including, but not limited to, running, biking, swimming, and59
73	69		strength training, so as to maximize the covered person's whole body health and both60
74	70		upper and lower limb function.61
75	71		(c) The coverage provided for in this Code section shall include no more than three62
76	72		orthotic devices or prosthetic devices per affected limb per covered person during any63
77	73		three-year period. Such coverage shall include:64
78	74		(1) All materials and components for the use of the orthotic device or prosthetic device,65
79	75		including:66
80	76		(A) The orthosis or prosthesis;67
81	77		(B) Structural components such as the socket;68
82	78		(C) Suspension mechanisms such as the pin, lock, suction, and elevated vacuum;69
83		-	S. B. 101
	79	+	S. B. 101 (SUB)
84	80		- 3 - 25 LC 60 0167S
85	81		(D) Hip joint, knee joint, foot, alignable parts, and terminal device;70
86	82		(E) Connective components such as pads, bands, and cushions; and71
87	83		(F) Consumable items such as socks, sleeves, and liners;72
88	84		(2) Formulation of the device's design, fabrication, measurements and fittings;73
89	85		(3) Education and training on using and maintaining such device; and74
90	86		(4) The repair of such device and its components.75
91	87		(d)(1) The replacement of an orthotic device or prosthetic device and its materials and76
92	88		components when such device is less than three years old shall be medically necessary77
93	89		if there is adequate documentation of a change in the physiological condition of the78
94	90		covered person, an irreparable change in the condition of the device or any of its79
95	91		components, or the condition of the device or a component of the device requires repairs80
96	92		and the cost of such repairs would be more than 60 percent of the cost of the device.81
97	93		(2) A socket replacement shall be medically necessary if there is adequate documentation82
98	94		of a physiological need, including, but not limited to, a change in the residual limb, a83
99	95		functional need change, irreparable damage, or wear and tear due to excessive weight of84
100	96		a covered person or physical demands of an active covered person.85
101	97		(e) A health insurer shall not be required to replace or repair an orthotic device or86
102	98		prosthetic device due to misuse, malicious damage, gross neglect, loss, or theft.87
103	99		(f) The coverage provided for in this Code section:88
104	100		(1) Shall be considered as habilitative or rehabilitative benefits for purposes of any state89
105	101		or federal requirements for coverage of essential health benefits;90
106	102		(2) Shall be comparable to coverage for other medical and surgical benefits under the91
107	103		health benefit policy, including restorative internal devices;92
108	104		(3) May be subject to the same cost-sharing requirements that apply to other medical93
109	105		devices and services covered by the health benefit policy; provided, however, that such94
110	106		requirements shall not be solely applicable to such coverage; and95
111		-	S. B. 101
	107	+	S. B. 101 (SUB)
112	108		- 4 - 25 LC 60 0167S
113	109		(4) May be limited, or the cost-sharing requirements for such coverage may be altered96
114	110		for out-of-network providers; provided, however, that any limitations shall not be more97
115	111		restrictive than the restrictions and requirements applicable to the out-of-network98
116	112		coverage for the policy's medical or surgical coverage.99
117	113		(g) Nothing in this Code section shall be construed to prohibit a health insurer from issuing100
118	114		or renewing a health benefit policy which provides benefits greater than the minimum101
119	115		benefits required under this Code section or from issuing or renewing a policy which102
120	116		provides benefits which are generally more favorable to the covered person than those103
121	117		required under this Code section.104
122	118		(h) By July 1, 2032, the Commissioner shall submit a report to the House Committee on105
123	119		Insurance and the Senate Insurance and Labor Committee regarding the implementation106
124	120		of the coverage required under this Code section. All health insurers issuing or renewing107
125	121		health benefit policies subject to the provisions of this Code section shall provide the108
126	122		department with all data requested by the department for inclusion in such report,109
127	123		including, but limited to, the total number of claims submitted, the total number of claims110
128	124		paid, and the total amount of claims paid for the coverage provided for by this Code section111
129	125		for policy years from 2026 to 2030.112
130	126		(i) The Commissioner shall promulgate rules and regulations necessary to implement the113
131	127		provisions of this Code section."114
132	128		SECTION 2.115
133	129		This Act shall become effective upon its approval by the Governor or upon its becoming law116
134	130		without such approval.117
135	131		SECTION 3.118
136	132		All laws and parts of laws in conflict with this Act are repealed.119
137		-	S. B. 101
	133	+	S. B. 101 (SUB)
138	134		- 5 -