Committee hears H.432 to expand insurance coverage to orthotics and activity‑specific prosthetics

Jen Harvey of the Office of Legislative Council opened discussion of H.432, saying, “This is H432. This is an act relating to health insurance coverage for prosthetic and orthotic devices.” The draft would expand the statutory definition of prosthetic devices to include orthotics and widen covered items to include activity‑specific devices (running, biking, swimming), waterproof devices for showering and bathing, instruction on use, and repair or replacement.

Harvey said the bill would replace older terms (insured/carrier) with covered individual/health insurance plan, require nondiscriminatory utilization‑review determinations and require plans to ensure access to at least two in‑state prosthetic/orthotic providers in‑network or provide out‑of‑network referral and reimbursed care when those providers are unavailable. She also noted insurer reporting requirements on claims and paid amounts by plan year and flagged a statutory effective‑date schedule and reporting deadlines to the commissioner of financial regulation.

Blue Cross and Blue Shield of Vermont’s Courtney Harness told the committee the insurer supports many goals in the bill but emphasized fiscal uncertainty. “Given our current cost of care in the system, it's actually more expensive just for an ambulance ride than it would be for us to pay for the prosthetic,” Harness said, urging the committee to consider potential premium impacts. Harness reported Blue Cross processed 223 prosthetic‑related claims in the last seven years, with roughly 20 waterproof/showering claims averaging about $15,000, and said the most complex daily prostheses can range from about $40,000 to $110,000.

Advocates and clinicians pushed back that the measure targets a narrow set of services. Kyle (participant on the Zoom line) summarized utilization evidence: “The average cost of a activity specific prosthesis or orthosis is 11,250,” and he said only patients who meet higher functional K‑levels (3 or 4) are likely to medically qualify for activity‑specific devices. David Heiler of the Everybody Can Move initiative added clinical context: “Anything that replaces a missing part would be considered a prosthetic, and anything that helps to enhance a damaged or injured part would be an orthotic.”

Committee members focused on practical limits and enforcement. Jurisdictional and program questions included whether Medicaid would be affected; Legislative Council said Medicaid is governed differently and the bill’s current draft may or may not include Medicaid in the definition of a health insurance plan and should be clarified. Members also discussed prior authorization and DME exemptions; witnesses said prior authorization serves as a protection for small providers and that utilization review and clinician judgment would naturally limit a surge of claims.

Rather than push a vote, the committee asked insurers and stakeholders to refine numbers and policy options. Harness agreed to provide member‑level ranges for Vermonters covered by Blue Cross and to confer with other stakeholders; committee leadership proposed a letter asking insurers and Medicaid to work with advocacy groups and return with concrete eligibility and cost estimates.

Next steps: the committee requested follow‑up data from insurers and advocates and signaled continued review of H.432’s scope, Medicaid inclusion, and potential state fiscal exposure under the federal state‑defray rule. The committee did not take a formal vote on H.432 during this session.