Kansas bill would set coverage and access rules for limb devices

Individual and group health policies covering hospital, medical, or surgical care would cover prosthetic and orthotic devices. The rule covers individual and group policies that pay hospital, medical, or surgical expenses. Coverage would include the device that best meets the enrollee's medical needs for daily activities, work, exercise, and bathing, plus necessary supplies and instructions. A provider could require confirmation of medical need when a device or part is less than three years old. Replacement would be covered when an ordering provider finds it necessary because of a physical change, irreparable damage, or repair costs above 60% of replacement cost. The rules would apply to policies and contracts issued, continued, or renewed in Kansas on or after January 11, 2027. Contracts would count as renewed by their next yearly anniversary, and the act would take effect after publication in the statute book.

Plans covering these devices would follow rules for treating the coverage and deciding whether to pay for it. These rules cover Kansas health plans that offer prosthetic or orthotic device coverage; the rehabilitative and habilitative classification applies to individual health plans. Individual plans would count the coverage as rehabilitative and habilitative care for essential health benefit requirements. A treating provider would have to find an additional device medically necessary for physical activities. Insurers could review claims, but could not deny coverage solely because of actual or perceived disability, or deny a benefit for limb loss or difference that would be covered for a nondisabled person seeking the same ability. Plans would explain these rights in coverage documents and denial letters. Separate financial requirements would not apply, but ordinary cost sharing for medical and surgical devices could apply. The rules would apply to policies and contracts issued, continued, or renewed in Kansas on or after January 11, 2027, and the act would take effect after publication in the statute book.

Plans covering these devices would provide access to at least two in-state providers in managed care networks. The two-provider rule applies to managed care networks; the out-of-network payment rule applies when a needed covered device is unavailable in-network. If a needed covered device is unavailable from an in-network provider, the insurer would fully reimburse an out-of-network provider at a rate agreed by both sides, minus the member's cost sharing calculated at the in-network level. The rules would apply to policies and contracts issued, continued, or renewed in Kansas on or after January 11, 2027, and the act would take effect after publication in the statute book.