H 5626

HOUSE . . . . . . . . No. 5626
  The Commonwealth of Massachusetts
  ________________________________________
  HOUSE OF REPRESENTATIVES, July 30, 2026.
   The committee on Ways and Means, to whom was referred the Bill to
improve outcomes for persons with limb loss and limb difference (House,
No. 4549), reports recommending that the same ought to pass with an
amendment substituting therefor the accompanying bill (House, No.
5626).
  For the committee,
  AARON MICHLEWITZ.
  FILED ON: 7/30/2026
HOUSE . . . . . . . . . . . . . . . No. 5626
  The Commonwealth of Massachusetts
  _______________
  In the One Hundred and Ninety-Fourth General Court
  (2025-2026)
  _______________
     An Act to improve outcomes for persons with limb loss and limb difference.
  Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
     of the same, as follows:
1SECTION 1. Section 17I of chapter 32A of the General Laws, as appearing in the 2024
2 Official Edition, is hereby amended by striking out subsections (a) and (b) and inserting in place
3 thereof the following 2 subsections:-
4(a) As used in this section, the following words shall, unless the context clearly requires
5 otherwise, have the following meanings:
6“Custom orthotic device”, a custom designed, custom fabricated, custom fitted,
7 prefabricated or modified orthotic device.
8“Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of
9 the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
10 appropriately used in a person’s home or any setting in which normal life activities take place in
11 the community.
  1 of 24
12“Orthotic services”, the design, fabrication and fitting of orthotic devices that help
13 support weak or unstable joints or limbs, correct alignment, relieve pain or improve function.
14 “Orthotic services” shall include, but shall not be limited to, spinal orthotic devices, scoliosis
15 orthotic devices, knee orthotic devices, cranial remolding orthotic devices and knee-ankle-foot
16 orthotic devices.
17“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg,
18 including a device that is designed specifically for physical activities.
19“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace
20 a missing body part due to amputation, trauma or congenital limb absence or difference.
21(b) The commission shall provide coverage for prosthetic devices and repairs to any
22 active or retired employee of the commonwealth who is insured under the group insurance
23 commission under the same terms and conditions that apply to other durable medical equipment
24 covered under the policy, except as otherwise provided in this section.
25SECTION 2. Said section 17I of said chapter 32A, as so appearing, is hereby further
26 amended by inserting after the word “devices”, in line 29, the following words:- ; provided, that
27 any prior authorization pursuant to this section shall be reviewed in a nondiscriminatory manner;
28 and provided further, that the commission shall not deny coverage for habilitative or
29 rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an
30 enrollee’s actual or perceived disability.
31SECTION 3. Said section 17I of said chapter 32A, as so appearing, is hereby further
32 amended by adding the following 2 subsections:-
  2 of 24
33(g) In addition to primary prosthetic devices and orthotic devices for daily use, the
34 commission shall provide coverage for prosthetic devices and orthotic devices designed, custom-
35 built or fitted for a specific enrollee for the performance of physical activities, including
36 prosthetic devices or orthotic devices specifically designed for showering and bathing, as
37 applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize
38 upper limb function. The coverage required pursuant to this subsection shall include the repair or
39 replacement of a prosthetic device or orthotic device for the performance of physical activities.
40(h)(1) The commission shall consider benefits pursuant to this section habilitative or
41 rehabilitative for purposes of any state or federal requirement for coverage of essential health
42 benefits.
43(2) The commission shall render utilization determinations in a nondiscriminatory
44 manner and shall not deny coverage for habilitative or rehabilitative benefits, including
45 prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived
46 disability.
47(3) The commission shall not deny a prosthetic or orthotic benefit for an enrollee with
48 limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
49 or surgical intervention to restore or maintain the ability to perform the same physical activity.
50(4) Prosthetic device and custom orthotic device coverage shall not be subject to separate
51 financial requirements that are applicable only with respect to that coverage. Such coverage may
52 include cost-sharing on prosthetic devices or custom orthotic devices; provided, that any cost-
  3 of 24
53 sharing requirements shall not be more restrictive than the cost-sharing requirements applicable
54 to the plan’s coverage for inpatient physician and surgical services.
55(5) If the commission provides coverage for prosthetic services or orthotic services, the
56 commission shall ensure access to medically necessary clinical care and to prosthetic devices and
57 custom orthotic devices and technology from not less than 2 distinct prosthetic and custom
58 orthotic providers in the managed care plan’s provider network located in the commonwealth. If
59 medically necessary covered orthotic devices and prosthetic devices are not available from an in-
60 network provider, the commission shall provide processes to refer an enrollee to an out-of-
61 network provider and shall fully reimburse the out-of-network provider at a mutually agreed
62 upon rate less enrollee cost-sharing determined on an in-network basis.
63(6) If coverage for prosthetic devices or custom orthotic devices is provided, payment
64 shall be made for the replacement of a prosthetic device or custom orthotic device or for the
65 replacement of any part of the prosthetic device or custom orthotic device, without regard to
66 continuous use or useful lifetime restrictions, if an ordering health care provider determines that
67 a replacement prosthetic device or custom orthotic device, or a replacement part of the prosthetic
68 device or custom orthotic device, is necessary for reasons which shall include, but shall not be
69 limited to: (i) a change in the physiological condition of the enrollee; (ii) an irreparable change in
70 the condition of the device or in a part of the device; or (iii) the condition of the device, or a part
71 of the device requires repairs and the cost of such repairs would be more than 60 per cent of the
72 cost of a replacement device or of the part being replaced. Confirmation from a prescribing
73 health care provider may be required if the prosthetic or custom orthotic device or part being
74 replaced is less than 3 years old.
  4 of 24
75SECTION 4. Chapter 118E of the General Laws is hereby amended by inserting after
76 section 10AA the following section:-
77Section 10BB. (a) As used in this section, the following words shall, unless the context
78 clearly requires otherwise, have the following meanings:
79“Custom orthotic device”, a custom designed, custom fabricated, custom fitted,
80 prefabricated or modified orthotic device.
81“Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of
82 the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
83 appropriately used in a person’s home or any setting in which normal life activities take place in
84 the community.
85“Orthotic services”, the design, fabrication and fitting of orthotic devices that help
86 support weak or unstable joints or limbs, correct alignment, relieve pain or improve function.
87 “Orthotic services” shall include, but shall not be limited to, spinal orthotic devices, scoliosis
88 orthotic devices, knee orthotic devices, cranial remolding orthotic devices and knee-ankle-foot
89 orthotic devices.
90“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg,
91 including a device that is designed specifically for physical activities.
92“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace
93 a missing body part due to amputation, trauma or congenital limb absence or difference.
  5 of 24
94(b)(1) The division and its contracted health insurers, health plans, health maintenance
95 organizations, behavioral health management firms and third-party administrators under contract
96 to a Medicaid managed care organization, accountable care organization or primary care
97 clinician plan shall provide coverage for prosthetic devices and orthotic devices, including the
98 repair or replacement of prosthetic devices or orthotic devices, under the same terms and
99 conditions that apply to other durable medical equipment. The coverage required by this section
100 shall be subject to the terms and conditions applicable to other benefits.
101(2) The division shall consider benefits pursuant to this section habilitative or
102 rehabilitative for purposes of any state or federal requirement for coverage of essential health
103 benefits.
104(3) The division and its contracted health insurers, health plans, health maintenance
105 organizations, behavioral health management firms and third-party administrators under contract
106 to a Medicaid managed care organization, accountable care organization or primary care
107 clinician plan shall render utilization determinations in a nondiscriminatory manner and shall not
108 deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic
109 devices, solely on the basis of an enrollee’s actual or perceived disability.
110(4) The division and its contracted health insurers, health plans, health maintenance
111 organizations, behavioral health management firms and third-party administrators under contract
112 to a Medicaid managed care organization, accountable care organization or primary care
113 clinician plan shall not deny a prosthetic or orthotic benefit for an enrollee with limb loss or
114 absence that would otherwise be covered for a non-disabled person seeking medical or surgical
115 intervention to restore or maintain the ability to perform the same physical activity.
  6 of 24
116(5) Prosthetic and custom orthotic device coverage shall not be subject to separate
117 financial requirements that are applicable only with respect to that coverage. An individual
118 health plan may impose cost-sharing on prosthetic or custom orthotic devices; provided, that any
119 cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
120 applicable to the plan’s coverage for inpatient physician and surgical services.
121(6) The division and its contracted health insurers, health plans, health maintenance
122 organizations, behavioral health management firms and third-party administrators under contract
123 to a Medicaid managed care organization, accountable care organization or primary care
124 clinician plan that provides coverage for prosthetic services or orthotic services shall ensure
125 access to medically necessary clinical care and to prosthetic and custom orthotic devices and
126 technology from not less than 2 distinct prosthetic and custom orthotic providers in the managed
127 care plan’s provider network located in the commonwealth. If medically necessary covered
128 orthotics and prosthetics are not available from an in-network provider, the division and its
129 contracted health insurers, health plans, health maintenance organizations, behavioral health
130 management firms and third-party administrators under contract to a Medicaid managed care
131 organization, accountable care organization or primary care clinician plan shall provide
132 processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-
133 network provider at a mutually agreed upon rate less enrollee cost-sharing determined on an in-
134 network basis.
135(7) If coverage for prosthetic devices or custom orthotic devices are provided by the
136 division and its contracted health insurers, health plans, health maintenance organizations,
137 behavioral health management firms and third-party administrators under contract to a Medicaid
  7 of 24
138 managed care organization, accountable care organization or primary care clinician plan,
139 payment shall be made for the replacement of a prosthetic device or custom orthotic device or for
140 the replacement of any part of the prosthetic device or custom orthotic device, without regard to
141 continuous use or useful lifetime restrictions, if an ordering health care provider determines that
142 a replacement prosthetic device or custom orthotic device, or a replacement part of a prosthetic
143 device or custom orthotic device, is necessary for reasons which shall include, but shall not be
144 limited to: (i) a change in the physiological condition of the enrollee; (ii) an irreparable change in
145 the condition of the device or in a part of the device; or (iii) the condition of the device, or a part
146 of the device requires repairs and the cost of such repairs would be more than 60 per cent of the
147 cost of a replacement device or of the part being replaced. Confirmation from a prescribing
148 health care provider may be required if the prosthetic or custom orthotic device or part being
149 replaced is less than 3 years old.
150(c) In addition to primary prosthetic devices and orthotic devices for daily use, the
151 division and its contracted health insurers, health plans, health maintenance organizations,
152 behavioral health management firms and third-party administrators under contract to a Medicaid
153 managed care organization, accountable care organization or primary care clinician plan shall
154 provide coverage for prosthetic devices and orthotic devices designed, custom-built or fitted for a
155 specific enrollee, for the performance of physical activities including devices specifically
156 designed for showering and bathing, as applicable, to maximize the enrollee’s ability to
157 ambulate, run, bike and swim and to maximize upper limb function. The coverage required
158 pursuant to this subsection shall include the repair or replacement of a prosthetic device or
159 orthotic device for the performance of physical activities.
  8 of 24
160(d) Eligible MassHealth members shall be required to provide detailed written orders,
161 which shall include a written prescription and statement of medical necessity from the
162 MassHealth member’s prescribing provider. The detailed written order shall include, but shall
163 not be limited to: (i) the member’s name and address; (ii) the member’s MassHealth
164 identification number; (iii) the specific identification of the prescribed item, including all options
165 or additional features that will be separately billed; (iv) the member’s diagnosis; (v) a statement
166 of medical necessity; (vi) the prescribing provider’s address and telephone number; and (vii) the
167 date on which the prescribing provider signed the detailed written order.
168SECTION 5. Section 47Z of chapter 175 of the General Laws, as appearing in the 2024
169 Official Edition, is hereby amended by striking out subsections (a) and (b) and inserting in place
170 thereof the following 2 subsections:-
171(a) As used in this section, the following words shall, unless the context clearly requires
172 otherwise, have the following meanings:
173“Custom orthotic device”, a custom designed, custom fabricated, custom fitted,
174 prefabricated or modified orthotic device.
175“Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of
176 the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
177 appropriately used in a person’s home or any setting in which normal life activities take place in
178 the community.
179“Orthotic services”, the design, fabrication and fitting of orthotic devices that help
180 support weak or unstable joints or limbs, correct alignment, relieve pain or improve function.
  9 of 24
181 “Orthotic services” shall include, but shall not be limited to, spinal orthotic devices, scoliosis
182 orthotic devices, knee orthotic devices, cranial remolding orthotic devices and knee-ankle-foot
183 orthotic devices.
184“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg,
185 including a device that is designed specifically for physical activities.
186“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace
187 a missing body part due to amputation, trauma or congenital limb absence or difference.
188(b) Any blanket or general policy of insurance, except a blanket or general policy of
189 insurance that provides supplemental coverage to Medicare or other governmental programs,
190 described in subdivision (A), (C) or (D) of section 110, which provides hospital expense and
191 surgical expense insurance and which is issued or subsequently renewed by agreement between
192 the insurer and the policy holder, within or without the commonwealth, during the period this
193 section is effective, or any policy of accident or sickness insurance, as described in section 108,
194 which provides hospital expense and surgical expense insurance, except a policy which provides
195 supplemental coverage to Medicare or other governmental programs, and which is delivered or
196 issued for delivery or subsequently renewed by agreement between the insurer and the policy
197 holder in the commonwealth, during the period that this section is effective, or any employees’
198 health and welfare fund, which provides hospital expense and surgical expense benefits and
199 which is promulgated or renewed to any person or group of persons in the commonwealth, while
200 this section is effective, shall provide coverage for prosthetic devices and repairs under the same
201 terms and conditions that apply to other durable medical equipment covered under the policy,
202 except as otherwise provided in this section.
  10 of 24
203SECTION 6. Said section 47Z of said chapter 175, as so appearing, is hereby further
204 amended by inserting after the word “devices”, in line 44, the following words:- ; provided, that
205 any prior authorization shall be reviewed in a nondiscriminatory manner; and provided further,
206 that no such policy shall deny coverage for habilitative or rehabilitative benefits, including
207 prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived
208 disability.
209SECTION 7. Said section 47Z of said chapter 175, as so appearing, is hereby further
210 amended by adding the following subsection:-
211(h)(1) In addition to primary prosthetic devices and orthotic devices for daily use, any
212 such policy shall provide coverage for prosthetic devices and orthotic devices designed, custom-
213 built or fitted for a specific enrollee for the performance of physical activities, including
214 prosthetic devices or orthotic devices specifically designed for showering and bathing, as
215 applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize
216 upper limb function. The coverage required pursuant to this subsection shall include the repair or
217 replacement of a prosthetic device or orthotic device for the performance of physical activities.
218(2) Any such policy shall consider benefits pursuant to this section habilitative or
219 rehabilitative for purposes of any state or federal requirement for coverage of essential health
220 benefits.
221(3) Any such policy shall render utilization determinations in a nondiscriminatory manner
222 and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic
223 devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived disability.
  11 of 24
224(4) Any such policy shall not deny a prosthetic or orthotic benefit for an enrollee with
225 limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
226 or surgical intervention to restore or maintain the ability to perform the same physical activity.
227(5) Prosthetic device and custom orthotic device coverage shall not be subject to separate
228 financial requirements that are applicable only with respect to that coverage. Any such policy
229 may include cost-sharing on prosthetic devices or custom orthotic devices; provided, that any
230 cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
231 applicable to the plan’s coverage for inpatient physician and surgical services.
232(6) A health plan that provides coverage for prosthetic services or orthotic services shall
233 ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic
234 devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in
235 the managed care plan’s provider network located in the commonwealth. If medically necessary
236 covered orthotic devices and prosthetic devices are not available from an in-network provider,
237 any such policy shall provide processes to refer an enrollee to an out-of-network provider and
238 shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee
239 cost-sharing determined on an in-network basis.
240(7) If coverage for prosthetic devices or custom orthotic devices is provided, payment
241 shall be made for the replacement of a prosthetic device or custom orthotic device or for the
242 replacement of any part of the prosthetic device or custom orthotic device, without regard to
243 continuous use or useful lifetime restrictions, if an ordering health care provider determines that
244 a replacement prosthetic device or custom orthotic device, or a replacement part of the prosthetic
245 device or custom orthotic device, is necessary for reasons which shall include, but shall not be
  12 of 24
246 limited to: (i) a change in the physiological condition of the enrollee; (ii) an irreparable change in
247 the condition of the device or in a part of the device; or (iii) the condition of the device, or a part
248 of the device requires repairs and the cost of such repairs would be more than 60 per cent of the
249 cost of a replacement device or of the part being replaced. Confirmation from a prescribing
250 health care provider may be required if the prosthetic or custom orthotic device or part being
251 replaced is less than 3 years old.
252SECTION 8. Section 8AA of chapter 176A of the General Laws, as so appearing, is
253 hereby amended by striking out subsections (a) and (b) and inserting in place thereof the
254 following 2 subsections:-
255(a) As used in this section, the following words shall, unless the context clearly requires
256 otherwise, have the following meanings:
257“Custom orthotic device”, a custom designed, custom fabricated, custom fitted,
258 prefabricated or modified orthotic device.
259“Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of
260 the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
261 appropriately used in a person’s home or any setting in which normal life activities take place in
262 the community.
263“Orthotic services”, the design, fabrication and fitting of orthotic devices that help
264 support weak or unstable joints or limbs, correct alignment, relieve pain or improve function.
265 “Orthotic services” shall include, but shall not be limited to, spinal orthotic devices, scoliosis
  13 of 24
266 orthotic devices, knee orthotic devices, cranial remolding orthotic devices and knee-ankle-foot
267 orthotic devices.
268“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg,
269 including a device that is designed specifically for physical activities.
270“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace
271 a missing body part due to amputation, trauma or congenital limb absence or difference.
272(b) A contract between a subscriber and the corporation under an individual or group
273 hospital service plan that provides hospital expense and surgical expense insurance, except
274 contracts providing supplemental coverage to Medicare or other governmental programs,
275 delivered, issued or renewed by agreement between the insurer and the policyholder, within or
276 without the commonwealth, shall provide benefits to all individual subscribers and members
277 within the commonwealth and to all group members having a principal place of employment
278 within the commonwealth for coverage for prosthetic devices and repairs. If prosthetic devices
279 are covered as a durable medical equipment benefit, coverage shall be provided under the same
280 terms and conditions that apply to other durable medical equipment covered under the contract,
281 except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone
282 benefit, coverage shall be consistent with the terms and conditions as described in this section.
283SECTION 9. Said section 8AA of said chapter 176A, as so appearing, is hereby further
284 amended by inserting after the word “devices”, in line 40, the following words:- ; provided, that
285 any prior authorization shall be reviewed in a nondiscriminatory manner; and provided further,
286 that no such contract shall deny coverage for habilitative or rehabilitative benefits, including
  14 of 24
287 prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived
288 disability.
289SECTION 10. Said section 8AA of said chapter 176A, as so appearing, is hereby further
290 amended by adding the following subsection:-
291(h)(1) In addition to primary prosthetic devices and orthotic devices for daily use, any
292 such contract shall provide coverage for prosthetic devices and orthotic devices designed,
293 custom-built or fitted for a specific enrollee for the performance of physical activities, including
294 prosthetic devices or orthotic devices specifically designed for showering and bathing, as
295 applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize
296 upper limb function. The coverage required pursuant to this subsection shall include the repair or
297 replacement of a prosthetic device or orthotic device for the performance of physical activities.
298(2) Any such contract shall consider benefits pursuant to this section habilitative or
299 rehabilitative for purposes of any state or federal requirement for coverage of essential health
300 benefits.
301(3) Any such contract shall render utilization determinations in a nondiscriminatory
302 manner and shall not deny coverage for habilitative or rehabilitative benefits, including
303 prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived
304 disability.
305(4) Any such contract shall not deny a prosthetic or orthotic benefit for an enrollee with
306 limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
307 or surgical intervention to restore or maintain the ability to perform the same physical activity.
  15 of 24
308(5) Prosthetic device and custom orthotic device coverage shall not be subject to separate
309 financial requirements that are applicable only with respect to that coverage. Any such contract
310 may include cost-sharing on prosthetic devices or custom orthotic devices; provided, that any
311 cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
312 applicable to the plan’s coverage for inpatient physician and surgical services.
313(6) A health plan that provides coverage for prosthetic services or orthotic services shall
314 ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic
315 devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in
316 the managed care plan’s provider network located in the commonwealth. If medically necessary
317 covered orthotic devices and prosthetic devices are not available from an in-network provider,
318 any such contract shall provide processes to refer an enrollee to an out-of-network provider and
319 shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee
320 cost-sharing determined on an in-network basis.
321(7) If coverage for prosthetic devices or custom orthotic devices is provided, payment
322 shall be made for the replacement of a prosthetic device or custom orthotic device or for the
323 replacement of any part of the prosthetic device or custom orthotic device, without regard to
324 continuous use or useful lifetime restrictions, if an ordering health care provider determines that
325 a replacement prosthetic device or custom orthotic device, or a replacement part of the prosthetic
326 device or custom orthotic device, is necessary for reasons which shall include, but shall not be
327 limited to: (i) a change in the physiological condition of the enrollee; (ii) an irreparable change in
328 the condition of the device or in a part of the device; or (iii) the condition of the device, or a part
329 of the device requires repairs and the cost of such repairs would be more than 60 per cent of the
  16 of 24
330 cost of a replacement device or of the part being replaced. Confirmation from a prescribing
331 health care provider may be required if the prosthetic or custom orthotic device or part being
332 replaced is less than 3 years old.
333SECTION 11. Section 4AA of chapter 176B of the General Laws, as so appearing, is
334 hereby amended by striking out subsections (a) and (b) and inserting in place thereof the
335 following 2 subsections:-
336(a) As used in this section, the following words shall, unless the context clearly requires
337 otherwise, have the following meanings:
338“Custom orthotic device”, a custom designed, custom fabricated, custom fitted,
339 prefabricated or modified orthotic device.
340“Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of
341 the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
342 appropriately used in a person’s home or any setting in which normal life activities take place in
343 the community.
344“Orthotic services”, the design, fabrication and fitting of orthotic devices that help
345 support weak or unstable joints or limbs, correct alignment, relieve pain or improve function.
346 “Orthotic services” shall include, but shall not be limited to, spinal orthotic devices, scoliosis
347 orthotic devices, knee orthotic devices, cranial remolding orthotic devices and knee-ankle-foot
348 orthotic devices.
349“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg,
350 including a device that is designed specifically for physical activities.
  17 of 24
351“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace
352 a missing body part due to amputation, trauma or congenital limb absence or difference.
353(b) Any subscription certificate under an individual or group medical service agreement,
354 except certificates that provide supplemental coverage to Medicare or other governmental
355 programs, that is delivered, issued or renewed within the commonwealth, shall provide, as
356 benefits to all individual subscribers or members within the commonwealth and to all group
357 members having a principal place of employment within the commonwealth, coverage for
358 prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment
359 benefit, coverage shall be provided under the same terms and conditions that apply to other
360 durable medical equipment covered under the policy, except as otherwise provided in this
361 section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be
362 consistent with the terms and conditions as described in this section.
363SECTION 12. Said section 4AA of said chapter 176B, as so appearing, is hereby further
364 amended by amended by inserting after the word “devices”, in line 38, the following words:- ;
365 provided, that any prior authorization shall be reviewed in a nondiscriminatory manner; and
366 provided further, that no such policy shall deny coverage for habilitative or rehabilitative
367 benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s
368 actual or perceived disability.
369SECTION 13. Said section 4AA of said chapter 176B, as so appearing, is hereby further
370 amended by adding the following subsection:-
  18 of 24
371(h)(1) In addition to primary prosthetic devices and orthotic devices for daily use, any
372 such certificate shall provide coverage for prosthetic devices and orthotic devices designed,
373 custom-built or fitted for a specific enrollee for the performance of physical activities, including
374 prosthetic devices or orthotic devices specifically designed for showering and bathing, as
375 applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize
376 upper limb function. The coverage required pursuant to this subsection shall include the repair or
377 replacement of a prosthetic device or orthotic device for the performance of physical activities.
378(2) Any such certificate shall consider benefits pursuant to this section habilitative or
379 rehabilitative for purposes of any state or federal requirement for coverage of essential health
380 benefits.
381(3) Any such certificate shall render utilization determinations in a nondiscriminatory
382 manner and shall not deny coverage for habilitative or rehabilitative benefits, including
383 prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived
384 disability.
385(4) Any such certificate shall not deny a prosthetic or orthotic benefit for an enrollee with
386 limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
387 or surgical intervention to restore or maintain the ability to perform the same physical activity.
388(5) Prosthetic device and custom orthotic device coverage shall not be subject to separate
389 financial requirements that are applicable only with respect to that coverage. Any such certificate
390 may include cost-sharing on prosthetic devices or custom orthotic devices; provided, that any
  19 of 24
391 cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
392 applicable to the plan’s coverage for inpatient physician and surgical services.
393(6) A health plan that provides coverage for prosthetic services or orthotic services shall
394 ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic
395 devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in
396 the managed care plan’s provider network located in the commonwealth. If medically necessary
397 covered orthotic devices and prosthetic devices are not available from an in-network provider,
398 any such certificate shall provide processes to refer an enrollee to an out-of-network provider and
399 shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee
400 cost-sharing determined on an in-network basis.
401(7) If coverage for prosthetic devices or custom orthotic devices is provided, payment
402 shall be made for the replacement of a prosthetic device or custom orthotic device or for the
403 replacement of any part of the prosthetic device or custom orthotic device, without regard to
404 continuous use or useful lifetime restrictions, if an ordering health care provider determines that
405 a replacement prosthetic device or custom orthotic device, or a replacement part of the prosthetic
406 device or custom orthotic device, is necessary for reasons which shall include, but shall not be
407 limited to: (i) a change in the physiological condition of the enrollee; (ii) an irreparable change in
408 the condition of the device or in a part of the device; or (iii) the condition of the device, or a part
409 of the device requires repairs and the cost of such repairs would be more than 60 per cent of the
410 cost of a replacement device or of the part being replaced. Confirmation from a prescribing
411 health care provider may be required if the prosthetic or custom orthotic device or part being
412 replaced is less than 3 years old.
  20 of 24
413SECTION 14. Section 4S of chapter 176G of the General Laws, as so appearing, is
414 hereby amended by striking out subsections (a) and (b) and inserting in place thereof the
415 following 2 subsections:-
416(a) As used in this section, the following words shall, unless the context clearly requires
417 otherwise, have the following meanings:
418“Custom orthotic device”, a custom designed, custom fabricated, custom fitted,
419 prefabricated or modified orthotic device.
420“Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of
421 the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
422 appropriately used in a person’s home or any setting in which normal life activities take place in
423 the community.
424“Orthotic services”, the design, fabrication and fitting of orthotic devices that help
425 support weak or unstable joints or limbs, correct alignment, relieve pain or improve function.
426 “Orthotic services” shall include, but shall not be limited to, spinal orthotic devices, scoliosis
427 orthotic devices, knee orthotic devices, cranial remolding orthotic devices and knee-ankle-foot
428 orthotic devices.
429“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg,
430 including a device that is designed specifically for physical activities.
431“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace
432 a missing body part due to amputation, trauma or congenital limb absence or difference.
  21 of 24
433(b) Individual and group health maintenance contracts shall provide coverage for
434 prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment
435 benefit, coverage shall be provided under the same terms and conditions that apply to other
436 durable medical equipment covered under the contracts, except as otherwise provided in this
437 section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be
438 consistent with the terms and conditions as described in this section.
439SECTION 15. Said section 4S of said chapter 176G, as so appearing, is hereby further
440 amended by inserting after the word “devices”, in line 33, the following words:- ; provided, that
441 any prior authorization shall be reviewed in a nondiscriminatory manner; and provided further,
442 that no such policy shall deny coverage for habilitative or rehabilitative benefits, including
443 prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived
444 disability.
445SECTION 16. Said section 4S of said chapter 176G, as so appearing, is hereby further
446 amended by adding the following subsection:-
447(h)(1) In addition to primary prosthetic devices and orthotic devices for daily use, a
448 health maintenance contract shall provide coverage for prosthetic devices and orthotic devices
449 designed, custom-built or fitted for a specific enrollee for the performance of physical activities,
450 including prosthetic devices or orthotic devices specifically designed for showering and bathing,
451 as applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to
452 maximize upper limb function. The coverage required pursuant to this subsection shall include
453 the repair or replacement of a prosthetic device or orthotic device for the performance of
454 physical activities.
  22 of 24
455(2) A health maintenance contract shall consider benefits pursuant to this section
456 habilitative or rehabilitative for purposes of any state or federal requirement for coverage of
457 essential health benefits.
458(3) A health maintenance contract shall render utilization determinations in a
459 nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits,
460 including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or
461 perceived disability.
462(4) A health maintenance contract shall not deny a prosthetic or orthotic benefit for an
463 enrollee with limb loss or absence that would otherwise be covered for a non-disabled person
464 seeking medical or surgical intervention to restore or maintain the ability to perform the same
465 physical activity.
466(5) Prosthetic device and custom orthotic device coverage shall not be subject to separate
467 financial requirements that are applicable only with respect to that coverage. A health
468 maintenance contract may include cost-sharing on prosthetic devices or custom orthotic devices;
469 provided, that any cost-sharing requirements shall not be more restrictive than the cost-sharing
470 requirements applicable to the plan’s coverage for inpatient physician and surgical services.
471(6) A health plan that provides coverage for prosthetic services or orthotic services shall
472 ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic
473 devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in
474 the managed care plan’s provider network located in the commonwealth. If medically necessary
475 covered orthotic devices and prosthetic devices are not available from an in-network provider, a
  23 of 24
476 health maintenance contract shall provide processes to refer an enrollee to an out-of-network
477 provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate
478 less enrollee cost-sharing determined on an in-network basis.
479(7) If coverage for prosthetic devices or custom orthotic devices is provided, payment
480 shall be made for the replacement of a prosthetic device or custom orthotic device or for the
481 replacement of any part of the prosthetic device or custom orthotic device, without regard to
482 continuous use or useful lifetime restrictions, if an ordering health care provider determines that
483 a replacement prosthetic device or custom orthotic device, or a replacement part of the prosthetic
484 device or custom orthotic device, is necessary for reasons which shall include, but shall not be
485 limited to: (i) a change in the physiological condition of the enrollee; (ii) an irreparable change in
486 the condition of the device or in a part of the device; or (iii) the condition of the device, or a part
487 of the device requires repairs and the cost of such repairs would be more than 60 per cent of the
488 cost of a replacement device or of the part being replaced. Confirmation from a prescribing
489 health care provider may be required if the prosthetic or custom orthotic device or part being
490 replaced is less than 3 years old.
  24 of 24