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Indiana Senate Bill SB0270

Indiana 2025 Regular Session

Indiana Senate Bill SB0270 Compare Versions

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1-*SB0270.1*
2-January 31, 2025
1+
2+Introduced Version
33 SENATE BILL No. 270
44 _____
5-DIGEST OF SB 270 (Updated January 30, 2025 3:19 pm - DI 140)
6-Citations Affected: IC 5-10; IC 27-1; IC 27-8; IC 27-13.
7-Synopsis: Coverage of orthotic and prosthetic devices. Sets forth
8-requirements for coverage of orthotic devices and prosthetic devices by
9-a state employee health plan, a policy of accident and sickness
10-insurance, and a health maintenance organization contract. Requires,
11-not later than October 1, 2026, the state personnel department, an
12-insurer that issues a policy of accident and sickness insurance, and a
13-health maintenance organization to submit a report to the insurance
14-commissioner regarding the total number of claims and the total
15-amount of claims paid for orthotic devices and prosthetic devices
16-during the preceding plan year. Requires the insurance commissioner
17-to: (1) aggregate the data received in the reports regarding coverage of
18-orthotic devices and prosthetic devices; and (2) report the aggregated
19-data, not later than December 1, 2026, to the standing committees of
20-the house of representatives and the senate that consider insurance
21-matters. Makes corresponding changes.
5+DIGEST OF INTRODUCED BILL
6+Citations Affected: IC 27.
7+Synopsis: Vehicle Bill.
228 Effective: July 1, 2025.
23-Hunley
9+Yoder
2410 January 13, 2025, read first time and referred to Committee on Rules and Legislative
2511 Procedure.
26-January 30, 2025, amended; reassigned to Committee on Insurance and Financial
27-Institutions.
28-SB 270—LS 6933/DI 13 January 31, 2025
12+2025 IN 270—LS 6933/DI 13 Introduced
2913 First Regular Session of the 124th General Assembly (2025)
3014 PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
3115 Constitution) is being amended, the text of the existing provision will appear in this style type,
3216 additions will appear in this style type, and deletions will appear in this style type.
3317 Additions: Whenever a new statutory provision is being enacted (or a new constitutional
3418 provision adopted), the text of the new provision will appear in this style type. Also, the
3519 word NEW will appear in that style type in the introductory clause of each SECTION that adds
3620 a new provision to the Indiana Code or the Indiana Constitution.
3721 Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
3822 between statutes enacted by the 2024 Regular Session of the General Assembly.
3923 SENATE BILL No. 270
4024 A BILL FOR AN ACT to amend the Indiana Code concerning
4125 insurance.
4226 Be it enacted by the General Assembly of the State of Indiana:
43-1 SECTION 1. IC 5-10-8-14, AS ADDED BY P.L.109-2008,
44-2 SECTION 1, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
45-3 JULY 1, 2025]: Sec. 14. (a) This section applies to a state employee
46-4 health plan that is established, entered into, amended, or renewed
47-5 after June 30, 2025.
48-6 (a) (b) As used in this section, "covered individual" means an
49-7 individual who is entitled to coverage under a state employee health
50-8 plan.
51-9 (b) (c) As used in this section, "orthotic device" means a medically
52-10 necessary custom fabricated brace or support that is designed as a
53-11 component of a prosthetic device.
54-12 (c) (d) As used in this section, "prosthetic device" means an
55-13 artificial leg or arm.
56-14 (d) (e) As used in this section, "state employee health plan" means
57-15 a:
58-16 (1) self-insurance program established under section 7(b) of this
59-17 chapter; or
60-SB 270—LS 6933/DI 13 2
61-1 (2) contract with a prepaid health care delivery plan that is
62-2 entered into or renewed under section 7(c) of this chapter;
63-3 to provide group health coverage. The term does not include a dental
64-4 or vision plan.
65-5 (e) (f) A state employee health plan must provide coverage for the
66-6 following:
67-7 (1) An orthotic devices and device or a prosthetic devices,
68-8 including repairs or replacements, device that is determined by
69-9 the covered individual's provider to be the most appropriate
70-10 model that adequately meets the medical needs of the covered
71-11 individual.
72-12 (1) are provided or performed by a person that is:
73-13 (A) accredited as required under 42 U.S.C. 1395m(a)(20); or
74-14 (B) a qualified practitioner (as defined in 42 U.S.C.
75-15 1395m(h)(1)(F)(iii));
76-16 (2) are An orthotic device or a prosthetic device that is
77-17 determined by the covered individual's physician provider to be
78-18 medically necessary to restore or maintain the covered
79-19 individual's ability to perform activities of daily living or essential
80-20 job related activities; and the most appropriate model that
81-21 meets the medical needs of the covered individual for
82-22 purposes of:
83-23 (A) performing physical activities, as applicable, such as
84-24 running, biking, swimming, and strength training; and
85-25 (B) maximizing the covered individual's whole body health
86-26 and lower or upper limb function.
87-27 (3) are not solely for comfort or convenience. An orthotic device
88-28 or a prosthetic device that is determined by the covered
89-29 individual's provider to be the most appropriate model that
90-30 meets the medical needs of the covered individual for
91-31 purposes of showering or bathing.
92-32 (4) All materials and components necessary to use the orthotic
93-33 devices and prosthetic devices described in subdivisions (1)
94-34 through (3).
95-35 (5) Instruction to the covered individual on using the orthotic
96-36 devices and prosthetic devices described in subdivisions (1)
97-37 through (3).
98-38 (6) The medically necessary repair or replacement of the
99-39 orthotic devices and prosthetic devices described in
100-40 subdivisions (1) through (3).
101-41 (g) With respect to a covered individual who receives an
102-42 orthotic device or a prosthetic device under subsection (f)(1),
103-SB 270—LS 6933/DI 13 3
104-1 coverage of an additional orthotic device or prosthetic device
105-2 under subsection (f)(2) or (f)(3) must require the covered
106-3 individual's treating physician to determine that the additional
107-4 orthotic device or prosthetic device under subsection (f)(2) or (f)(3)
108-5 is necessary to enable the covered individual to engage in the
109-6 activities described in subsection (f)(2) or (f)(3).
110-7 (f) (h) The:
111-8 (1) coverage required under subsection (e) (f) must be equal to
112-9 the coverage that is provided for the same device, repair, or
113-10 replacement under the federal Medicare program (42 U.S.C. 1395
114-11 et seq.) and the regulations under 42 CFR 410.100, 42 CFR
115-12 414.202, 42 CFR 414.210, and 42 CFR 414.228; and
116-13 (2) reimbursement under the coverage required under subsection
117-14 (e) (f) must be equal to the reimbursement that is provided for the
118-15 same device, repair, or replacement under the federal Medicare
119-16 reimbursement schedule, unless a different reimbursement rate is
120-17 negotiated.
121-18 This subsection does not require a deductible under a state employee
122-19 health plan to be equal to a deductible under the federal Medicare
123-20 program.
124-21 (g) (i) Except as provided in subsections (h) and (i), subsection (k),
125-22 the coverage required under subsection (e): (f):
126-23 (1) may be subject to; and
127-24 (2) may not be more restrictive than;
128-25 the provisions that apply to other benefits under the state employee
129-26 health plan.
130-27 (j) A state employee health plan shall consider the coverage
131-28 required under subsection (f) to be habilitative or rehabilitative
132-29 benefits for purposes of any state or federal requirement for
133-30 coverage of essential health benefits.
134-31 (h) (k) The coverage required under subsection (e) (f) may be
135-32 subject to utilization review, including periodic review, of the
136-33 continued medical necessity of the benefit. A state employee health
137-34 plan:
138-35 (1) shall render utilization review determinations in a
139-36 nondiscriminatory manner; and
140-37 (2) may not deny coverage for habilitative or rehabilitative
141-38 benefits, including orthotic devices or prosthetic devices,
142-39 solely on the basis of a covered individual's actual or
143-40 perceived disability.
144-41 (l) A state employee health plan may not deny coverage for an
145-42 orthotic device or a prosthetic device for a covered individual with
146-SB 270—LS 6933/DI 13 4
147-1 limb loss or absence that would otherwise be covered for a covered
148-2 individual without a disability who seeks medical or surgical
149-3 intervention to restore or maintain the ability to perform the same
150-4 physical activity.
151-5 (m) A state employee health plan shall include language
152-6 describing a covered individual's rights under subsections (k) and
153-7 (l) in the state employee health plan's evidence of coverage and any
154-8 denial letters.
155-9 (n) A state employee health plan shall ensure that covered
156-10 individuals have access to medically necessary clinical care and
157-11 orthotic devices and prosthetic devices from at least two (2) distinct
158-12 orthotic device and prosthetic device providers in the state
159-13 employee health plan's network. If medically necessary orthotic
160-14 devices and prosthetic devices are not available from an in network
161-15 provider, the state employee health plan shall:
162-16 (1) provide processes to refer a covered individual to an out
163-17 of network provider; and
164-18 (2) fully reimburse the out of network provider at a mutually
165-19 agreed upon rate reduced by the covered individual's cost
166-20 sharing determined on an in network basis.
167-21 (o) If a state employee health plan provides coverage for an
168-22 orthotic device or prosthetic device, the state employee health plan
169-23 shall provide coverage for the replacement of the orthotic device,
170-24 the prosthetic device, or any part of the orthotic device or
171-25 prosthetic device without regard to continuous use or useful
172-26 lifetime restrictions if an ordering provider determines that the
173-27 replacement device or part is necessary because of any of the
174-28 following:
175-29 (1) A change in the physiological condition of the covered
176-30 individual.
177-31 (2) An irreparable change in the condition of the device or
178-32 part.
179-33 (3) The condition of the device or part requires repairs and
180-34 the cost of the repairs would be more than sixty percent
181-35 (60%) of the cost of a replacement device or part.
182-36 The state employee health plan may require confirmation from a
183-37 prescribing provider if the device or part that is being replaced is
184-38 less than three (3) years old.
185-39 (i) Any lifetime maximum coverage limitation that applies to
186-40 prosthetic devices and orthotic devices:
187-41 (1) must not be included in; and
188-42 (2) must be equal to;
189-SB 270—LS 6933/DI 13 5
190-1 the lifetime maximum coverage limitation that applies to all other items
191-2 and services generally under the state employee health plan.
192-3 (j) (p) For purposes of this subsection, "items and services" does not
193-4 include preventive services for which coverage is provided under a
194-5 high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26
195-6 U.S.C. 223(c)(2)). The coverage required under subsection (e) (f) may
196-7 not be subject to a deductible, copayment, or coinsurance provision that
197-8 is less favorable to a covered individual than the deductible,
198-9 copayment, or coinsurance provisions that apply to other items and
199-10 services generally under the state employee health plan.
200-11 (q) Not later than October 1, 2026, the state personnel
201-12 department shall submit a report to the insurance commissioner
202-13 regarding a state employee's health plan coverage of orthotic
203-14 devices and prosthetic devices. The report must:
204-15 (1) be on a form prescribed by the insurance commissioner;
205-16 and
206-17 (2) include the total number of claims and the total amount of
207-18 claims paid for the services required under subsection (f)
208-19 during the preceding plan year.
209-20 This subsection expires June 30, 2027.
210-21 SECTION 2. IC 27-1-3-35.5 IS ADDED TO THE INDIANA CODE
211-22 AS A NEW SECTION TO READ AS FOLLOWS [EFFECTIVE JULY
212-23 1, 2025]: Sec. 35.5. (a) The commissioner shall aggregate the data
213-24 received under:
214-25 (1) IC 5-10-8-14;
215-26 (2) IC 27-8-24.2-11; and
216-27 (3) IC 27-13-7-19.
217-28 (b) Not later than December 1, 2026, the commissioner shall
218-29 submit a report regarding the aggregated data under subsection (a)
219-30 in an electronic format under IC 5-14-6 to the standing committees
220-31 of the house of representatives and the senate that consider
221-32 insurance matters.
222-33 (c) This section expires June 30, 2027.
223-34 SECTION 3. IC 27-8-24.2-0.1, AS ADDED BY P.L.220-2011,
224-35 SECTION 450, IS AMENDED TO READ AS FOLLOWS
225-36 [EFFECTIVE JULY 1, 2025]: Sec. 0.1. The addition of This chapter by
226-37 P.L.109-2008 applies to a policy of accident and sickness insurance
227-38 that is issued, delivered, amended, or renewed after June 30, 2008.
228-39 2025.
229-40 SECTION 4. IC 27-8-24.2-5, AS ADDED BY P.L.109-2008,
230-41 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
231-42 JULY 1, 2025]: Sec. 5. A policy of accident and sickness insurance
232-SB 270—LS 6933/DI 13 6
233-1 must provide coverage for the following:
234-2 (1) An orthotic devices and device or a prosthetic devices,
235-3 including repairs or replacements, device that is determined by
236-4 the insured's provider to be the most appropriate model that
237-5 adequately meets the medical needs of the insured.
238-6 (1) are provided or performed by a person that is:
239-7 (A) accredited as required under 42 U.S.C. 1395m(a)(20); or
240-8 (B) a qualified practitioner (as defined in 42 U.S.C.
241-9 1395m(h)(1)(F)(iii));
242-10 (2) are An orthotic device or a prosthetic device that is
243-11 determined by the insured's physician provider to be medically
244-12 necessary to restore or maintain the insured's ability to perform
245-13 activities of daily living or essential job related activities; and the
246-14 most appropriate model that meets the medical needs of the
247-15 insured for purposes of:
248-16 (A) performing physical activities, as applicable, such as
249-17 running, biking, swimming, and strength training; and
250-18 (B) maximizing the insured's whole body health and lower
251-19 or upper limb function.
252-20 (3) are not solely for comfort or convenience. An orthotic device
253-21 or a prosthetic device that is determined by the insured's
254-22 provider to be the most appropriate model that meets the
255-23 medical needs of the insured for purposes of showering or
256-24 bathing.
257-25 (4) All materials and components necessary to use the orthotic
258-26 devices and prosthetic devices described in subdivisions (1)
259-27 through (3).
260-28 (5) Instruction to the insured on using the orthotic devices and
261-29 prosthetic devices described in subdivisions (1) through (3).
262-30 (6) The medically necessary repair or replacement of the
263-31 orthotic devices and prosthetic devices described in
264-32 subdivisions (1) through (3).
265-33 SECTION 5. IC 27-8-24.2-5.5 IS ADDED TO THE INDIANA
266-34 CODE AS A NEW SECTION TO READ AS FOLLOWS
267-35 [EFFECTIVE JULY 1, 2025]: Sec. 5.5. With respect to an insured
268-36 who receives an orthotic device or a prosthetic device under section
269-37 5(1) of this chapter, coverage of an additional orthotic device or
270-38 prosthetic device under section 5(2) or 5(3) of this chapter must
271-39 require the insured's treating physician to determine that the
272-40 additional orthotic device or prosthetic device under section 5(2)
273-41 or 5(3) of this chapter is necessary to enable the insured to engage
274-42 in the activities described in section 5(2) or 5(3) of this chapter.
275-SB 270—LS 6933/DI 13 7
276-1 SECTION 6. IC 27-8-24.2-6, AS ADDED BY P.L.109-2008,
277-2 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
278-3 JULY 1, 2025]: Sec. 6. The:
279-4 (1) coverage required under section 5 of this chapter must be
280-5 equal to the coverage that is provided for the same device, repair,
281-6 or replacement under the federal Medicare program (42 U.S.C.
282-7 1395 et seq.) and the regulations under 42 CFR 410.100, 42
283-8 CFR 414.202, 42 CFR 414.210, and 42 CFR 414.228; and
284-9 (2) reimbursement under the coverage required under section 5 of
285-10 this chapter must be equal to the reimbursement that is provided
286-11 for the same device, repair, or replacement under the federal
287-12 Medicare reimbursement schedule, unless a different
288-13 reimbursement rate is negotiated.
289-14 This section does not require a deductible under a policy of accident
290-15 and sickness insurance to be equal to a deductible under the federal
291-16 Medicare program.
292-17 SECTION 7. IC 27-8-24.2-7, AS ADDED BY P.L.109-2008,
293-18 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
294-19 JULY 1, 2025]: Sec. 7. Except as provided in sections section 8 and 9
295-20 of this chapter, the coverage required under section 5 of this chapter:
296-21 (1) may be subject to; and
297-22 (2) may not be more restrictive than;
298-23 the provisions that apply to other benefits under the policy of accident
299-24 and sickness insurance.
300-25 SECTION 8. IC 27-8-24.2-7.5 IS ADDED TO THE INDIANA
301-26 CODE AS A NEW SECTION TO READ AS FOLLOWS
302-27 [EFFECTIVE JULY 1, 2025]: Sec. 7.5. A policy of accident and
303-28 sickness insurance shall consider the coverage required under
304-29 section 5 of this chapter to be habilitative or rehabilitative benefits
305-30 for purposes of any state or federal requirement for coverage of
306-31 essential health benefits.
307-32 SECTION 9. IC 27-8-24.2-8, AS ADDED BY P.L.109-2008,
308-33 SECTION 2, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
309-34 JULY 1, 2025]: Sec. 8. (a) The coverage required under section 5 of
310-35 this chapter may be subject to utilization review, including periodic
311-36 review, of the continued medical necessity of the benefit.
312-37 (b) A policy of accident and sickness insurance:
313-38 (1) shall render utilization review determinations in a
314-39 nondiscriminatory manner; and
315-40 (2) may not deny coverage for habilitative or rehabilitative
316-41 benefits, including orthotic devices or prosthetic devices,
317-42 solely on the basis of an insured's actual or perceived
318-SB 270—LS 6933/DI 13 8
319-1 disability.
320-2 SECTION 10. IC 27-8-24.2-8.3 IS ADDED TO THE INDIANA
321-3 CODE AS A NEW SECTION TO READ AS FOLLOWS
322-4 [EFFECTIVE JULY 1, 2025]: Sec. 8.3. A policy of accident and
323-5 sickness insurance may not deny coverage for an orthotic device or
324-6 a prosthetic device for an insured with limb loss or absence that
325-7 would otherwise be covered for an insured without a disability who
326-8 seeks medical or surgical intervention to restore or maintain the
327-9 ability to perform the same physical activity.
328-10 SECTION 11. IC 27-8-24.2-8.5 IS ADDED TO THE INDIANA
329-11 CODE AS A NEW SECTION TO READ AS FOLLOWS
330-12 [EFFECTIVE JULY 1, 2025]: Sec. 8.5. A policy of accident and
331-13 sickness insurance shall include language describing an insured's
332-14 rights under sections 8 and 8.3 of this chapter in the policy of
333-15 accident and sickness insurance's evidence of coverage and any
334-16 denial letters.
335-17 SECTION 12. IC 27-8-24.2-8.7 IS ADDED TO THE INDIANA
336-18 CODE AS A NEW SECTION TO READ AS FOLLOWS
337-19 [EFFECTIVE JULY 1, 2025]: Sec. 8.7. A policy of accident and
338-20 sickness insurance shall ensure that insureds have access to
339-21 medically necessary clinical care and orthotic devices and
340-22 prosthetic devices from at least two (2) distinct orthotic device and
341-23 prosthetic device providers in the policy of accident and sickness
342-24 insurance's network. If medically necessary orthotic devices and
343-25 prosthetic devices are not available from an in network provider,
344-26 the policy of accident and sickness insurance shall:
345-27 (1) provide processes to refer an insured to an out of network
346-28 provider; and
347-29 (2) fully reimburse the out of network provider at a mutually
348-30 agreed upon rate reduced by the insured's cost sharing
349-31 determined on an in network basis.
350-32 SECTION 13. IC 27-8-24.2-9 IS REPEALED [EFFECTIVE JULY
351-33 1, 2025]. Sec. 9. Any lifetime maximum coverage limitation that
352-34 applies to prosthetic devices and orthotic devices:
353-35 (1) must not be included in; and
354-36 (2) must be equal to;
355-37 the lifetime maximum coverage limitation that applies to all other items
356-38 and services generally under the policy of accident and sickness
357-39 insurance.
358-40 SECTION 14. IC 27-8-24.2-9.5 IS ADDED TO THE INDIANA
359-41 CODE AS A NEW SECTION TO READ AS FOLLOWS
360-42 [EFFECTIVE JULY 1, 2025]: Sec. 9.5. If a policy of accident and
361-SB 270—LS 6933/DI 13 9
362-1 sickness insurance provides coverage for an orthotic device or
363-2 prosthetic device, the policy of accident and sickness insurance
364-3 shall provide coverage for the replacement of the orthotic device,
365-4 the prosthetic device, or any part of the orthotic device or
366-5 prosthetic device without regard to continuous use or useful
367-6 lifetime restrictions if an ordering provider determines that the
368-7 replacement device or part is necessary because of any of the
369-8 following:
370-9 (1) A change in the physiological condition of the insured.
371-10 (2) An irreparable change in the condition of the device or
372-11 part.
373-12 (3) The condition of the device or part requires repairs and
374-13 the cost of the repairs would be more than sixty percent
375-14 (60%) of the cost of a replacement device or part.
376-15 The policy of accident and sickness insurance may require
377-16 confirmation from a prescribing provider if the device or part that
378-17 is being replaced is less than three (3) years old.
379-18 SECTION 15. IC 27-8-24.2-11 IS ADDED TO THE INDIANA
380-19 CODE AS A NEW SECTION TO READ AS FOLLOWS
381-20 [EFFECTIVE JULY 1, 2025]: Sec. 11. (a) Not later than October 1,
382-21 2026, an insurer that issues a policy of accident and sickness
383-22 insurance shall submit a report to the commissioner regarding the
384-23 policy of accident and sickness insurance's coverage of orthotic
385-24 devices and prosthetic devices. The report must:
386-25 (1) be on a form prescribed by the commissioner; and
387-26 (2) include the total number of claims and the total amount of
388-27 claims paid for the services required under section 5 of this
389-28 chapter during the preceding plan year.
390-29 (b) This section expires June 30, 2027.
391-30 SECTION 16. IC 27-13-7-19, AS ADDED BY P.L.109-2008,
392-31 SECTION 3, IS AMENDED TO READ AS FOLLOWS [EFFECTIVE
393-32 JULY 1, 2025]: Sec. 19. (a) This section applies to an individual
394-33 contract and a group contract that is entered into, delivered,
395-34 amended, or renewed after June 30, 2025.
396-35 (a) (b) As used in this section, "orthotic device" means a medically
397-36 necessary custom fabricated brace or support that is designed as a
398-37 component of a prosthetic device.
399-38 (b) (c) As used in this section, "prosthetic device" means an
400-39 artificial leg or arm.
401-40 (c) (d) An individual contract or a group contract that provides
402-41 coverage for basic health care services must provide coverage for the
403-42 following:
404-SB 270—LS 6933/DI 13 10
405-1 (1) An orthotic devices and device or a prosthetic devices,
406-2 including repairs or replacements, device that is determined by
407-3 the enrollee's provider to be the most appropriate model that
408-4 adequately meets the medical needs of the enrollee.
409-5 (1) are provided or performed by a person that is:
410-6 (A) accredited as required under 42 U.S.C. 1395m(a)(20); or
411-7 (B) a qualified practitioner (as defined in 42 U.S.C.
412-8 1395m(h)(1)(F)(iii));
413-9 (2) are An orthotic device or a prosthetic device that is
414-10 determined by the enrollee's physician provider to be medically
415-11 necessary to restore or maintain the enrollee's ability to perform
416-12 activities of daily living or essential job related activities; and the
417-13 most appropriate model that meets the medical needs of the
418-14 enrollee for purposes of:
419-15 (A) performing physical activities, as applicable, such as
420-16 running, biking, swimming, and strength training; and
421-17 (B) maximizing the enrollee's whole body health and lower
422-18 or upper limb function.
423-19 (3) are not solely for comfort or convenience. An orthotic device
424-20 or a prosthetic device that is determined by the enrollee's
425-21 provider to be the most appropriate model that meets the
426-22 medical needs of the enrollee for purposes of showering or
427-23 bathing.
428-24 (4) All materials and components necessary to use the orthotic
429-25 devices and prosthetic devices described in subdivisions (1)
430-26 through (3).
431-27 (5) Instruction to the enrollee on using the orthotic devices
432-28 and prosthetic devices described in subdivisions (1) through
433-29 (3).
434-30 (6) The medically necessary repair or replacement of the
435-31 orthotic devices and prosthetic devices described in
436-32 subdivisions (1) through (3).
437-33 (e) With respect to an enrollee who receives an orthotic device
438-34 or a prosthetic device under subsection (d)(1), coverage of an
439-35 additional orthotic device or prosthetic device under subsection
440-36 (d)(2) or (d)(3) must require the enrollee's treating physician to
441-37 determine that the additional orthotic device or prosthetic device
442-38 under subsection (d)(2) or (d)(3) is necessary to enable the enrollee
443-39 to engage in the activities described in subsection (d)(2) or (d)(3).
444-40 (d) (f) The:
445-41 (1) coverage required under subsection (c) (d) must be equal to
446-42 the coverage that is provided for the same device, repair, or
447-SB 270—LS 6933/DI 13 11
448-1 replacement under the federal Medicare program (42 U.S.C. 1395
449-2 et seq.) and the regulations under 42 CFR 410.100, 42 CFR
450-3 414.202, 42 CFR 414.210, and 42 CFR 414.228; and
451-4 (2) reimbursement under the coverage required under subsection
452-5 (c) (d) must be equal to the reimbursement that is provided for the
453-6 same device, repair, or replacement under the federal Medicare
454-7 reimbursement schedule, unless a different reimbursement rate is
455-8 negotiated.
456-9 This subsection does not require a deductible under an individual
457-10 contract or a group contract to be equal to a deductible under the
458-11 federal Medicare program.
459-12 (e) (g) Except as provided in subsections (f) and (g), subsection (i),
460-13 the coverage required under subsection (c): (d):
461-14 (1) may be subject to; and
462-15 (2) may not be more restrictive than;
463-16 the provisions that apply to other benefits under the individual contract
464-17 or group contract.
465-18 (h) An individual contract or a group contract shall consider the
466-19 coverage required under subsection (d) to be habilitative or
467-20 rehabilitative benefits for purposes of any state or federal
468-21 requirement for coverage of essential health benefits.
469-22 (f) (i) The coverage required under subsection (c) (d) may be
470-23 subject to utilization review, including periodic review, of the
471-24 continued medical necessity of the benefit. An individual contract or
472-25 a group contract:
473-26 (1) shall render utilization review determinations in a
474-27 nondiscriminatory manner; and
475-28 (2) may not deny coverage for habilitative or rehabilitative
476-29 benefits, including orthotic devices or prosthetic devices,
477-30 solely on the basis of an enrollee's actual or perceived
478-31 disability.
479-32 (j) An individual contract or a group contract may not deny
480-33 coverage for an orthotic device or a prosthetic device for an
481-34 enrollee with limb loss or absence that would otherwise be covered
482-35 for an enrollee without a disability who seeks medical or surgical
483-36 intervention to restore or maintain the ability to perform the same
484-37 physical activity.
485-38 (k) An individual contract or a group contract shall include
486-39 language describing an enrollee's rights under subsections (i) and
487-40 (j) in the individual contract or group contract's evidence of
488-41 coverage and any denial letters.
489-42 (l) An individual contract or a group contract shall ensure that
490-SB 270—LS 6933/DI 13 12
491-1 enrollees have access to medically necessary clinical care and
492-2 orthotic devices and prosthetic devices from at least two (2) distinct
493-3 orthotic device and prosthetic device providers in the individual
494-4 contract or group contract's network. If medically necessary
495-5 orthotic devices and prosthetic devices are not available from an
496-6 in network provider, the individual contract or group contract
497-7 shall:
498-8 (1) provide processes to refer an enrollee to an out of network
499-9 provider; and
500-10 (2) fully reimburse the out of network provider at a mutually
501-11 agreed upon rate reduced by the enrollee's cost sharing
502-12 determined on an in network basis.
503-13 (m) If an individual contract or a group contract provides
504-14 coverage for an orthotic device or prosthetic device, the individual
505-15 contract or group contract shall provide coverage for the
506-16 replacement of the orthotic device, the prosthetic device, or any
507-17 part of the orthotic device or prosthetic device without regard to
508-18 continuous use or useful lifetime restrictions if an ordering
509-19 provider determines that the replacement device or part is
510-20 necessary because of any of the following:
511-21 (1) A change in the physiological condition of the enrollee.
512-22 (2) An irreparable change in the condition of the device or
513-23 part.
514-24 (3) The condition of the device or part requires repairs and
515-25 the cost of the repairs would be more than sixty percent
516-26 (60%) of the cost of a replacement device or part.
517-27 The individual contract or group contract may require
518-28 confirmation from a prescribing provider if the device or part that
519-29 is being replaced is less than three (3) years old.
520-30 (g) Any lifetime maximum coverage limitation that applies to
521-31 prosthetic devices and orthotic devices:
522-32 (1) must not be included in; and
523-33 (2) must be equal to;
524-34 the lifetime maximum coverage limitation that applies to all other items
525-35 and services generally under the individual contract or group contract.
526-36 (h) (n) For purposes of this subsection, "items and services" does
527-37 not include preventive services for which coverage is provided under
528-38 a high deductible health plan (as defined in 26 U.S.C. 220(c)(2) or 26
529-39 U.S.C. 223(c)(2)). The coverage required under subsection (c) (d) may
530-40 not be subject to a deductible, copayment, or coinsurance provision that
531-41 is less favorable to an enrollee than the deductible, copayment, or
532-42 coinsurance provisions that apply to other items and services generally
533-SB 270—LS 6933/DI 13 13
534-1 under the individual contract or group contract.
535-2 (o) Not later than October 1, 2026, a health maintenance
536-3 organization that enters into an individual contract or a group
537-4 contract that provides coverage for basic health care services shall
538-5 submit a report to the commissioner regarding the individual
539-6 contract or group contract's coverage of orthotic devices and
540-7 prosthetic devices. The report must:
541-8 (1) be on a form prescribed by the commissioner; and
542-9 (2) include the total number of claims and the total amount of
543-10 claims paid for the services required under subsection (d)
544-11 during the preceding plan year.
545-12 This subsection expires June 30, 2027.
546-SB 270—LS 6933/DI 13 14
547-COMMITTEE REPORT
548-Mr. President: The Senate Committee on Rules and Legislative
549-Procedure, to which was referred Senate Bill No. 270, has had the same
550-under consideration and begs leave to report the same back to the
551-Senate with the recommendation that said bill be AMENDED as
552-follows:
553-Delete everything after the enacting clause and insert the following:
554-(SEE TEXT OF BILL)
555-and when so amended that said bill be reassigned to the Senate
556-Committee on Insurance and Financial Institutions.
557-(Reference is to SB 270 as introduced.)
558-BRAY, Chairperson
559-SB 270—LS 6933/DI 13
27+1 SECTION 1. IC 27 is amended concerning insurance.
28+2025 IN 270—LS 6933/DI 13