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Bill > AB1121

WI AB1121

WI AB1121
Health insurance coverage of prosthetic limbs and custom orthotic braces. (FE)

summary

Introduced
03/13/2026
In Committee
03/13/2026
Crossed Over
Passed
Dead
03/23/2026

Introduced Session

2025-2026 Regular Session

Bill Summary

This bill requires health insurance policies and self-insured governmental health plans to provide coverage of prosthetic limbs and custom orthotic braces (devices) when medically necessary for an individual to participate in activities of daily living or essential job-related activities or to perform physical activities for maximizing limb function, or to meet the individual’s medical needs for purposes of showering or bathing. The bill specifies that coverage must include the materials, components, and related services necessary to use a device for its intended purpose; any instruction provided to the individual on using the device; and the reasonable repair of the device. The bill also requires coverage of more significant repairs or replacement of the device, without regard to continuous use or useful lifetime restrictions, when medically necessary due to a change in the individual’s physiological condition or an irreparable change in the device’s condition or if the cost to repair the device exceeds 60 percent of the device’s replacement cost. The bill requires that the coverage must be, at a minimum, equal to the coverage and payment for prosthetic and orthotic devices provided under the federal Medicare program. The bill provides that the coverage may only be subject to the cost-sharing provisions that apply generally to the coverage provided under the policy or plan for inpatient physician and surgical services. The bill also requires that a managed care plan must ensure access to medically necessary clinical care and the devices from at least two in-network providers in this state. If the care and services are not available from an in-network provider, the managed care plan must provide a process to refer an individual to an out-of-network provider and must fully reimburse that provider at a mutually agreed upon rate. This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats. For further information see the state fiscal estimate, which will be printed as an appendix to this bill.

AI Summary

This bill mandates that health insurance policies and self-insured governmental health plans, including those for state and local government employees, must cover prosthetic limbs (devices that replace or restore missing limbs or their function) and custom orthotic braces (external medical devices fitted to support or correct musculoskeletal issues) when deemed medically necessary. This medical necessity is defined as being required for daily living, essential job activities, maximizing limb function through physical activities, or for personal hygiene like showering. The coverage must include all necessary materials, components, instructions for use, and reasonable repairs, and importantly, it must also cover significant repairs or replacements if medically necessary due to changes in the individual's physical condition or if repair costs exceed 60% of the replacement cost, regardless of how long the device has been used. The bill specifies that this coverage must be at least as good as that provided by Medicare, and any cost-sharing for these devices can only be the same as that for inpatient physician and surgical services. Furthermore, managed care plans must ensure access to at least two in-network providers in the state for these services and must have a process for referring individuals to out-of-network providers and fully reimbursing them if in-network care is unavailable. This proposal may require a report on its social and financial impact.

Committee Categories

Business and Industry

Sponsors (23)

Last Action

Failed to pass pursuant to Senate Joint Resolution 1 (on 03/23/2026)
(1 Companion Bills)

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