IN THE SENATE OF THE UNITED STATES
August 6, 2020
Mr. Warner (for himself, Mr. Daines, Ms. Duckworth, Mr. Cassidy, and Mr. Cornyn) introduced the following bill; which was read twice and referred to the Committee on Finance
To amend title XVIII of the Social Security Act to protect beneficiaries with limb loss and other orthopedic conditions by providing access to appropriate, safe, effective, patient-centered orthotic and prosthetic care, to reduce fraud, waste, and abuse with respect to orthotics and prosthetics, and for other purposes.
This Act may be cited as the
Medicare Orthotics and Prosthetics Patient-Centered Care Act.
Increasing protections for beneficiaries receiving orthotic and prosthetic care under the Medicare program
Distinguishing orthotists and prosthetists from suppliers of durable medical equipment and supplies
Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended—
in subsection (j)(5), by striking subparagraph (C) and redesignating the subsequent subparagraphs accordingly; and
by adding at the end the following new subsection:
Requirements for orthotists and prosthetists
Issuance and renewal of supplier number
No payment may be made under this part to an orthotic or prosthetic supplier unless such orthotic or prosthetic supplier obtains (and renews at such intervals as the Secretary may require) a supplier number.
Clarification regarding providers under part A
Nothing in clause (i) shall prohibit a provider otherwise permitted to receive payment for orthotics and prosthetics under part A from continuing to receive payment under such part without interruption.
Standards for possessing a supplier number
An orthotic or prosthetic supplier may only obtain a supplier number if the supplier meets standards prescribed by the Secretary that include requirements that the orthotic or prosthetic supplier (and, where applicable, the orthotist or prosthetist)—
licensure and accreditation—
complies with all applicable State and Federal licensure and regulatory requirements; and
acquires accreditation from the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. or the Board of Certification/Accreditation, International, or other accreditation entity that the Secretary determines has standards that are equivalent to the standards of such Boards;
maintains a physical facility on an appropriate site;
has proof of appropriate liability insurance; and
meets such other requirements as the Secretary shall specify.
Prohibition against multiple supplier numbers
The Secretary may not issue more than one supplier number to any orthotic or prosthetic supplier unless the Secretary finds that the issuance of more than one number is appropriate to identify other entities under the ownership or control of the orthotic or prosthetic supplier.
Order for orthotics or prosthetics
Information provided by orthotists and prosthetists on detailed written orders for orthotics and prosthetics
An orthotist or prosthetist may distribute to physicians, physician assistants, nurse practitioners, clinical nurse specialists, or individuals entitled to benefits under this part, a detailed written order for orthotics or prosthetics (as defined in paragraph (5)) for commercial purposes that contains the following information:
The identification of—
the orthotic or prosthetic supplier; and
the individual to whom the orthotics or prosthetics are furnished.
The identification of the treating physician, physician assistant, nurse practitioner, or clinical nurse specialist.
A description of the orthotics or prosthetics ordered.
The date of the order described in this subparagraph.
Information on coding and descriptors of components provided
If an orthotist or prosthetist distributes a detailed written order for orthotics or prosthetics described in subparagraph (A), the orthotist or prosthetist shall also list on the order the summary descriptors of the items and services being recommended prior to submission of the order to the treating physician for approval.
Signature by treating physician
A detailed written order for orthotics or prosthetics described in subparagraph (A) shall be signed by the treating physician.
Limitation on patient liability
Except as provided in paragraph (4), if an orthotist or prosthetist—
furnishes an orthosis or prosthesis to a beneficiary for which no payment may be made under this part; or
subject to section 1879, furnishes an orthosis or prosthesis to a beneficiary for which payment is denied under section 1862(a)(1),
If an orthotist or prosthetist furnishes an orthosis or prosthesis to a patient for which payment is denied in advance under subsection (a)(15), expenses incurred for such orthosis or prosthesis furnished to the individual by the orthotist or prosthetist shall be the responsibility of the individual.
In this subsection:
Detailed written order for orthotics or prosthetics
detailed written order for orthotics or prosthetics means a form or other document prepared by an orthotist or prosthetist and signed by the physician (as defined by section 1861(r)) that contains information required by the Secretary to show that an orthosis or prosthesis is reasonable and necessary for the treatment of an illness or injury or to improve the functioning of a malformed body member.
The detailed written order for orthotics or prosthetics shall not be considered alone for purposes of determining the reasonableness, medical necessity, and functional level (applicable to prosthetics) of orthotics and prosthetics.
Orthotics and prosthetics
orthotics and prosthetics has the meaning given that term in section 1834(h)(4)(C).
Orthotist or prosthetist
orthotist or prosthetist means an individual who is specifically trained and educated in the provision of, and patient care management related to, prosthetics and custom-fabricated or custom-fit orthotics, and—
in the case of a State that provides for the licensing of orthotists and prosthetists, is licensed by the State in which the orthotics or prosthetics were supplied; or
in the case of a State that does not provide for the licensing of orthotists and prosthetists, is certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc. or by the Board of Certification/Accreditation, International, or is certified and approved by an entity that the Secretary determines has certification and approval standards that are essentially equivalent to the certification and approval standards of such Boards.
Prohibiting payment for certain orthotics and prosthetics
Section 1834(h)(1) of the Social Security Act (42 U.S.C. 1395m(h)(1)) is amended by adding at the end the following new subparagraph:
Special payment rules for orthotics or prosthetics
No payment shall be made under this subsection for—
a prosthesis (excluding prosthetic supplies) that is delivered by drop shipment;
a custom-fabricated or custom-fitted orthosis (excluding orthotic supplies) described in subparagraph (F)(ii) that is delivered by drop shipment; and
an orthotic item that is not otherwise competitively bid that is delivered by drop shipment.
Drop shipment defined
In this subparagraph, the term
drop shipment means the shipping of an orthosis or prosthesis to a beneficiary without receiving from a trained, educated, and certified or licensed health care practitioner, orthotist, or prosthetist direct patient care with respect to assessing, adjusting, and training in the care and use of the orthosis or prosthesis.
Standardizing the definitions of orthotics and prosthetics
Section 1834(h)(4) of the Social Security Act (42 U.S.C. 1395m(h)(4)) is amended—
in subparagraph (B), by striking at the end
in subparagraph (C)—
the term and inserting
orthotics and prosthetics has the meaning given such term
the terms ; and
orthotics and prosthetics and
orthoses and prostheses have the meaning given such terms
by striking the period at the end and inserting
; and; and
by inserting after subparagraph (C), as amended by paragraph (2), the following new subparagraph:
prostheses refer to a device (including the clinical services associated with such device) that replaces all or part of a limb.
Limitation of competitive acquisition for off-the-Shelf orthotics
Section 1847(a) of the Social Security Act (42 U.S.C. 1395w–3(a)) is amended—
in paragraph (2)(C), by inserting
by the patient (and not by another person) after
minimal self-adjustment; and
in paragraph (7)(A)(i)—
, orthotist or prosthetist (as defined in section 1834(x)(5)(C)), after
by a physician;
, orthotist’s or prosthetist’s, after
to the physician’s; and
, orthotist’s or prosthetist’s, after
of the physician’s.
Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate final regulations to implement the provisions of, and amendments made by, this Act.