Concerning coverage requirements for prosthetic limbs and custom orthotic braces.

Group plans cover prosthetic limbs and braces

The law takes effect July 27, 2025. Beginning January 1, 2026, covered Washington small- and large-group plans must cover prosthetic limbs and custom orthotic braces. The requirement applies to plans issued or renewed on or after that date. Coverage includes one or more prostheses per limb and custom braces per limb for medically needed daily tasks, essential work, or physical activities that maximize limb function. These devices replace or restore missing limbs or provide patient-specific support for movement problems. Coverage includes needed materials, parts, related services, instructions for use, and reasonable repairs or replacements. Plans cannot enforce continuous-use or useful-life limits on medically needed repairs or replacements when your physical condition changes, a device or part changes beyond repair, or repair costs exceed 60% of replacement cost. For items less than three years old, plans may require confirmation from the prescribing provider before replacement. Plans may still use normal coverage reviews and prior approval. They cannot deny a disabled person coverage for an activity when they cover services for a nondisabled person seeking that activity. Denials must be written and explain why the service was not medically necessary. Payments must at least match the applicable federal payment and coverage standards for aged and disabled people. The mandate excludes individual-market plans and self-insured or fully insured large-group plans for public and school employees under state chapter 41.05. Insurers must report claim counts and total payments for plan years 2026 and 2027 by July 1, 2028. The state insurance commissioner must combine the data by plan year and report to legislative committees by December 1, 2028.