WASHINGTON—Legislation that would require group health plans to cover prosthetic care at the same level as other medical and surgical care has been introduced in Congress, but its prospect of passage is unclear, experts say.

Under the Prosthetic Parity Act introduced in the House of Representatives earlier this month by Rep. Robert Andrews, D-N.J., with bipartisan support, group health plans also could not "impose any annual or lifetime dollar limitation on benefits for prosthetic devices and components unless such limitation applies in the aggregate to all medical and surgical benefits."

While the legislation says health insurers have started limiting prosthetic costs that they will cover at "unrealistic levels," health insurers and employers say the extra costs of a prosthetic coverage mandate likely would be passed down to employers in higher premiums.

"It's worrisome because the employer loses control over what they are paying for," said Steve Wojcik, vp of public policy at the Washington-based National Business Group on Health.

The federal push for parity for prosthetic coverage gained momentum after achieving some success at the state level in which nine states have passed such laws. Colorado was the first state to pass a prosthetic parity measure in 2000, with New Jersey and Indiana becoming the latest states to pass similar measures this year. Similar proposals are being considered in 30 other states. However, because of a pre-emption provision in the Employee Retirement Income Security Act, state laws do not apply to health care plans that are self-funded. The federal legislation would apply to both self-funded and fully-insured plans.

"The main goal is to create a nationwide standard of coverage that is consistent and appropriate so we can secure protection for the thousands of amputees who are facing enormous obstacles," said Morgan Sheets, director of the Amputee Coalition of America, the Knoxville, Tenn.-based advocacy group that has championed the legislation.

Coverage for prostheses varies widely, and a growing number of insurers are limiting coverage by imposing low dollar caps and restrictions, the ACA says.

Many private health plans cap coverage at $2,500 or $5,000 a year or limit a patient to one device per lifetime, according to a 2006 ACA survey of its members' health plans. In addition, 29% of amputees with private health insurance had prosthetic coverage reduced during the past three years while 8% had coverage eliminated completely, according to 2007 ACA data.

The cost of prosthetics ranges from less than $100 to $15,000 for basic devices while mechanical and computer-assisted models can cost as much as $30,000, according to the ACA.

While proponents say providing parity of prosthetic coverage would boost health insurance premiums by less than $1 per month, employer groups warn that any benefit mandate impacts health insurance affordability and puts additional financial pressure on employers.

"Companies will lose the ability to cover what their resources will allow," Mr. Wojcik said.

While the success at the state level may increase pressure to pass the federal bill, health care experts say it is difficult to predict how the bill will fare in Congress.

"It is very difficult to pass mandatory health care legislation. There is a lot of resistance in Congress to do it," said Tom Billet, a senior consultant with Watson Wyatt Worldwide in Stamford, Conn.

Parity for prosthetic coverage may face hurdles similar to those experienced by mental health parity legislation, he said.

The House earlier this month cleared its version of the mental health parity legislation on a 268-148 vote (BI, March 10). That action, following last year's Senate passage of a more limited parity measure, sets the stage for a conference committee to try to work out the differences between the two bills. Congress first passed mental health care parity legislation in 1996 and the latest bills would expand that law.

"Look how long it has taken to produce bills on mental health parity legislation. This can be an arduous process," Mr. Billet said.

Aside from the mental health care parity measure, other health care benefit mandates that Congress has approved include a 1978 law that requires group health care plans to provide the same coverage for pregnancy and childbirth; a 1986 law that requires employers to extend group health coverage to former employees and dependents in termination of employment, death and divorce situations; and another 1996 law that requires health plans to offer at least 48 hours of inpatient coverage after a vaginal birth and 96 hours of coverage after a Caesarean.