Advocacy Alert: Insurance Coverage for Kids’ Prosthetics & Orthotics

HB406/SB422 Ensures children and young adults age 21 and under have access to medically appropriate prosthetic and custom orthotic devices through private insurance plans without discrimination or arbitrary coverage limits.

TN House Insurance Committee will hear this bill in committee on Tuesday, February 17th at 10:30am CT.

Why This Matters:

• Children grow, and prosthetic needs change frequently.
• Current insurance practices often:
• Cover only basic mobility devices
• Deny devices for activities like swimming, running, showering, or playing sports
• Impose unrealistic replacement timelines inconsistent with child growth

This bill ensures coverage reflects medical necessity, not insurer preference to provide the best quality of life possible for children with limb differences.

Applies to: Private health benefit plans issued or renewed in Tennessee on or after July 1, 2026

Population: Covered individuals 21 years of age and under, consistent with who is considered a child under the Tenncare program and the Tennessee Department of Education Special Education Services

Coverage must:

• Meet or exceed Medicare standards
• Be no more restrictive than coverage for other medical devices

Devices covered include those needed for:

• Activities of daily living (showering)
• Physical activities (running, swimming, cycling, team sports)
• Maximizing whole-body health and limb function

Coverage is based on provider medical judgment, not insurer substitution.

Consumer Protections:

Insurers may not:

• Deny coverage based on actual or perceived disability
• Impose higher cost-sharing than inpatient physician or surgical services
• Apply arbitrary “useful lifetime” limits on devices
• Children with limb loss must be treated no differently than children receiving care to restore physical function.

Repair or replacement must be covered when:

• A child’s physical condition changes
• A device becomes irreparable
• Repair costs exceed 60% of replacement
• Provider confirmation may be required only if the device is less than 3 years old.

Network Access:

• Plans must offer access any network orthotic and prosthetic provider
• If necessary devices are unavailable in-network:
• Out-of-network access must be allowed
• Providers must be fully reimbursed at in-network cost-sharing levels.

Oversight & Transparency

• Insurers must submit annual data to the Department of Commerce and Insurance.
• Reports are provided to the General Assembly for oversight.

Action Alert: Contact the TN House Insurance Committee in support of this bill before their committee meeting on Tuesday 2/17.

Contact Information: