OAR 836-052-1000: Prosthetic and Orthotic Devices

(1) For purposes of this rule, the term device has the meaning given under ORS 743A.145. (2) The list of devices that must be covered under ORS 743A.145, includes: (a) Any device for which the Centers for Medicare and Medicaid Services (CMS) has established an L Code in the Healthcare Common Procedure Coding System (HCPCS) Level II, as of January 1, 2026; and (b) Any additional devices that are determined to be medically necessary and the most appropriate model that meets the medical needs of the insured for purposes of performing physical activities, including but not limited to running, biking, swimming and strength training, and that maximizes the insured’s whole-body health, including lower and upper limb function. (3) Coverage for the devices and supplies described in subsection (2) of this section may not be subject to internal or separate limits or caps other than the policy lifetime maximum benefits. This subsection does not authorize a health benefit plan or other policy of health insurance to impose a lifetime or annual dollar limit that is otherwise prohibited under state or federal law. (4) For purposes of ORS 743A.145, coverage provided through a managed care organization includes a health insurance policy that requires an enrollee to use a closed network of providers managed, owned, under contract with or employed by the insurer in order to receive benefits under the plan.