Bill > SB5629

This bill requires nongrandfathered group health plans (excluding small group and public employee plans) to provide comprehensive coverage for prosthetic limbs and custom orthotic braces starting January 1, 2026. The coverage must support enrollees in completing daily living activities, job-related tasks, and physical activities like running, biking, swimming, and strength training to maximize limb function. The bill mandates that coverage include not just the devices themselves, but also materials, components, related services, user instructions, and reasonable repair or replacement. Importantly, the bill allows device replacement without lifetime restrictions if medically necessary, such as due to changes in the patient's physiological condition, device damage, or when repair costs exceed 60% of replacement costs. The legislation also prohibits denying coverage for individuals with disabilities if similar medical services would be covered for non-disabled individuals and requires that any coverage denials be provided in writing with a clear explanation. Additionally, the bill stipulates that payment for these prosthetic and orthotic services must meet federal standards for aged and disabled individuals, ensuring a baseline level of comprehensive support for those needing such medical devices.

Health and Social Services

https://app.leg.wa.gov/billsummary?BillNumber=5629&Year=2025&Initiative=false