Massachusetts 2025-2026 Regular Session

Massachusetts Senate Bill S811 Compare Versions

Only one version of the bill is available at this time.

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1	1	1 of 1
2	2	SENATE DOCKET, NO. 1134 FILED ON: 1/15/2025
3	3	SENATE . . . . . . . . . . . . . . No. 811
4	4	The Commonwealth of Massachusetts
5	5	_________________
6	6	PRESENTED BY:
7	7	Jacob R. Oliveira
8	8	_________________
9	9	To the Honorable Senate and House of Representatives of the Commonwealth of Massachusetts in General
10	10	Court assembled:
11	11	The undersigned legislators and/or citizens respectfully petition for the adoption of the accompanying bill:
12	12	An Act to improve outcomes for those with limb loss and limb difference.
13	13	_______________
14	14	PETITION OF:
15	15	NAME:DISTRICT/ADDRESS :Jacob R. OliveiraHampden, Hampshire and Worcester 1 of 15
16	16	SENATE DOCKET, NO. 1134 FILED ON: 1/15/2025
17	17	SENATE . . . . . . . . . . . . . . No. 811
18	18	By Mr. Oliveira, a petition (accompanied by bill, Senate, No. 811) of Jacob R. Oliveira for
19	19	legislation to provide coverage for prosthetic and orthotic devices including the repair or
20	20	replacement of prosthetic or orthotic devices to eligible MassHealth members. Financial
21	21	Services.
22	22	The Commonwealth of Massachusetts
23	23	_______________
24	24	In the One Hundred and Ninety-Fourth General Court
25	25	(2025-2026)
26	26	_______________
27	27	An Act to improve outcomes for those with limb loss and limb difference.
28	28	Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority
29	29	of the same, as follows:
30	30	1 SECTION 1. Section 17I of chapter 32A of the General Laws, as so appearing in the
31	31	22022 Official Edition, is hereby amended by striking out subsection (b) and inserting in place
32	32	3thereof the following subsection:-
33	33	4 (b) For the purposes of this section the following words shall, unless the context clearly
34	34	5requires otherwise, have the following meanings:
35	35	6 “Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body,
36	36	7which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
37	37	8appropriately used in a person’s home or any setting in which normal life activities take place in
38	38	9the community.
39	39	10 “Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg
40	40	11including a device that is designed specifically for physical activities. 2 of 15
41	41	12 SECTION 2. Subsection (f) of said section 17I of said chapter 32A of the General Laws,
42	42	13as so appearing, is hereby amended by inserting after the word “devices” the following words:-
43	43	14but must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or
44	44	15rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s
45	45	16actual or perceived disability.
46	46	17 SECTION 3. Said section 17I of said chapter 32A, as so appearing, is hereby further
47	47	18amended by adding the following subsections:-
48	48	19 (g) In addition to primary prosthetic and orthotic devices for daily use, the commission
49	49	20shall provide coverage for prosthetic devices and orthotic devices designed, custom-built or
50	50	21fitted for a specific enrollee for the performance of physical activities, including devices
51	51	22specifically designed for showering and bathing, as applicable, to maximize the enrollee’s ability
52	52	23to ambulate, run, bike and swim and to maximize upper limb function. The coverage required
53	53	24pursuant to this subsection shall include the repair or replacement of a prosthetic or orthotic
54	54	25device for the performance of physical activities.
55	55	26 (h)(1): The division shall consider these benefits habilitative or rehabilitative for purposes
56	56	27of any state or federal requirement for coverage of essential health benefits.
57	57	28 (h)(2): An insurer shall render utilization determinations in a nondiscriminatory manner
58	58	29and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or
59	59	30orthotics, solely on the basis of an insured’s actual or perceived disability.
60	60	31 (h)(3): An insurer shall not deny a prosthetic or orthotic benefit for an individual with
61	61	32limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
62	62	33or surgical intervention to restore or maintain the ability to perform the same physical activity. 3 of 15
63	63	34 (h)(4): Prosthetic and custom orthotic device coverage shall not be subject to separate
64	64	35financial requirements that are applicable only with respect to that coverage, An individual
65	65	36health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any
66	66	37cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
67	67	38applicable to the plan’s coverage for inpatient physician and surgical services.
68	68	39 (h)(5): A health plan that provides coverage for prosthetic or orthotic services shall
69	69	40ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices
70	70	41and technology from not less than two distinct prosthetic and custom orthotic providers in the
71	71	42managed care plan’s provider network located in the state. In the event that medically necessary
72	72	43covered orthotics and prosthetics are not available from an in-network provider, the insurer shall
73	73	44provide processes to refer a member to an out-of-network provider and shall fully reimburse the
74	74	45out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on
75	75	46an in-network basis.
76	76	47 (h)(6): If coverage for prosthetic or custom orthotic devices is provided, payment shall be
77	77	48made for the replacement of a prosthetic or custom orthotic device or for the replacement of any
78	78	49part of such devices, without regard to continuous use or useful lifetime restrictions, if an
79	79	50ordering health care provider determines that the provision of a replacement device, or a
80	80	51replacement part of such a device, is necessary for reasons which shall include, but not be limited
81	81	52to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the
82	82	53condition of the device or in a part of the device; or (iii) the condition of the device, or the part of
83	83	54the devices requires repairs and the cost of such repairs would be more than sixty percent of the
84	84	55cost of a replacement device or of the part being replaced. 4 of 15
85	85	56 Confirmation from a prescribing health care provider may be required if the prosthetic or
86	86	57custom orthotic device or part being replaced is less than three years old.
87	87	58 SECTION 4. Chapter 118E of the General Laws, as so appearing, is hereby amended by
88	88	59inserting after section 10Q the following section:-
89	89	60 Section 10R. (a) For the purposes of this section the following words shall, unless the
90	90	61context clearly requires otherwise, have the following meanings:
91	91	62 “Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of
92	92	63the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
93	93	64appropriately used in a person’s home or any setting in which normal life activities take place in
94	94	65the community.
95	95	66 “Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg
96	96	67including a device that is designed specifically for physical activities.
97	97	68 (b)(1) The division shall provide coverage for prosthetic and orthotic devices including
98	98	69the repair or replacement of prosthetic or orthotic devices to eligible MassHealth members under
99	99	70the same terms and conditions that apply to other durable medical equipment. The coverage
100	100	71required by this section shall be subject to the terms and conditions applicable to other benefits.
101	101	72 (b)(2): The division shall consider these benefits habilitative or rehabilitative for purposes
102	102	73of any state or federal requirement for coverage of essential health benefits.
103	103	74 (b)(3): An insurer shall render utilization determinations in a nondiscriminatory manner
104	104	75and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or
105	105	76orthotics, solely on the basis of an insured’s actual or perceived disability. 5 of 15
106	106	77 (b)(4): An insurer shall not deny a prosthetic or orthotic benefit for an individual with
107	107	78limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
108	108	79or surgical intervention to restore or maintain the ability to perform the same physical activity.
109	109	80 (b)(5): Prosthetic and custom orthotic device coverage shall not be subject to separate
110	110	81financial requirements that are applicable only with respect to that coverage, An individual
111	111	82health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any
112	112	83cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
113	113	84applicable to the plan’s coverage for inpatient physician and surgical services.
114	114	85 (b)(6): A health plan that provides coverage for prosthetic or orthotic services shall
115	115	86ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices
116	116	87and technology from not less than two distinct prosthetic and custom orthotic providers in the
117	117	88managed care plan’s provider network located in the state. In the event that medically necessary
118	118	89covered orthotics and prosthetics are not available from an in-network provider, the insurer shall
119	119	90provide processes to refer a member to an out-of-network provider and shall fully reimburse the
120	120	91out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on
121	121	92an in-network basis.
122	122	93 (b)(7): If coverage for prosthetic or custom orthotic devices is provided, payment shall be
123	123	94made for the replacement of a prosthetic or custom orthotic device or for the replacement of ant
124	124	95part of such devices, without regard to continuous use or useful lifetime restrictions, if an
125	125	96ordering health care provider determines that the provision of a replacement device, or a
126	126	97replacement part of such a device, is necessary for reasons which shall include, but not be limited
127	127	98to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the 6 of 15
128	128	99condition of the device or in a part of the device; or (iii) the condition of the device, or the part of
129	129	100the devices requires repairs and the cost of such repairs would be more than sixty percent of the
130	130	101cost of a replacement device or of the part being replaced.
131	131	102 Confirmation from a prescribing health care provider may be required if the prosthetic or
132	132	103custom orthotic device or part being replaced is less than three years old.
133	133	104 (c) In addition to primary prosthetic and orthotic devices for daily use, the division shall
134	134	105provide coverage for prosthetic devices and orthotic devices custom-built or fitted for a specific
135	135	106enrollee, for the performance of physical activities including devices specifically designed for
136	136	107showering and bathing, as applicable, to maximize the enrollee’s ability to ambulate, run, bike
137	137	108and swim and to maximize upper limb function. The coverage required pursuant to this
138	138	109subsection shall include the repair or replacement of a prosthetic or orthotic device for the
139	139	110performance of physical activities.
140	140	111 (d) Eligible MassHealth members shall be required to provide a written prescription
141	141	112signed by a licensed physician or an independent nurse practitioner. The prescription must be
142	142	113written on the prescriber's prescription form and must include the following information:(i) the
143	143	114member's name and address; (ii) the member’s MassHealth identification number; (iii) specific
144	144	115identification of the prescribed item; (iv) medical justification for the use of the item, including
145	145	116the member’s diagnosis; (v) the prescriber's address and telephone number; and (vi) the date on
146	146	117which the prescription was signed by the prescriber.
147	147	118 SECTION 5. Section 47Z of chapter 175 of the General Laws, as so appearing, is hereby
148	148	119amended by striking out subsection (b) and inserting in place thereof the following subsection:- 7 of 15
149	149	120 (b) For the purposes of this section the following words shall, unless the context clearly
150	150	121requires otherwise, have the following meanings:
151	151	122 “Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body,
152	152	123which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
153	153	124appropriately used in a person’s home or any setting in which normal life activities take place in
154	154	125the community.
155	155	126 “Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg
156	156	127including a device that is designed specifically for physical activities.
157	157	128 SECTION 6. Subsection (f) of said section 47Z of said chapter 175 of the General Laws,
158	158	129as so appearing, is hereby amended by inserting after the word “devices” the following words:-
159	159	130but must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or
160	160	131rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s
161	161	132actual or perceived disability.
162	162	133 SECTION 7. Said section 47Z of said chapter 175, as so appearing, is hereby further
163	163	134amended by adding the following subsection:-
164	164	135 (h) Any such policy shall provide coverage for prosthetic devices and orthoses for daily
165	165	136use, in addition to prosthetic devices and orthoses designed, custom-built or fitted for a specific
166	166	137enrollee for the performance of physical activities, as applicable, to maximize the enrollee’s
167	167	138ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage
168	168	139required pursuant to this subsection shall include the repair or replacement of a prosthetic or
169	169	140orthotic device for the performance of physical activities. 8 of 15
170	170	141 (h)(1): The division shall consider these benefits habilitative or rehabilitative for purposes
171	171	142of any state or federal requirement for coverage of essential health benefits.
172	172	143 (h)(2): An insurer shall render utilization determinations in a nondiscriminatory manner
173	173	144and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or
174	174	145orthotics, solely on the basis of an insured’s actual or perceived disability.
175	175	146 (h)(3): An insurer shall not deny a prosthetic or orthotic benefit for an individual with
176	176	147limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
177	177	148or surgical intervention to restore or maintain the ability to perform the same physical activity.
178	178	149 (h)(4): Prosthetic and custom orthotic device coverage shall not be subject to separate
179	179	150financial requirements that are applicable only with respect to that coverage, An individual
180	180	151health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any
181	181	152cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
182	182	153applicable to the plan’s coverage for inpatient physician and surgical services.
183	183	154 (h)(5): A health plan that provides coverage for prosthetic or orthotic services shall
184	184	155ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices
185	185	156and technology from not less than two distinct prosthetic and custom orthotic providers in the
186	186	157managed care plan’s provider network located in the state. In the event that medically necessary
187	187	158covered orthotics and prosthetics are not available from an in-network provider, the insurer shall
188	188	159provide processes to refer a member to an out-of-network provider and shall fully reimburse the
189	189	160out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on
190	190	161an in-network basis. 9 of 15
191	191	162 (h)(6): If coverage for prosthetic or custom orthotic devices is provided, payment shall be
192	192	163made for the replacement of a prosthetic or custom orthotic device or for the replacement of any
193	193	164part of such devices, without regard to continuous use or useful lifetime restrictions, if an
194	194	165ordering health care provider determines that the provision of a replacement device, or a
195	195	166replacement part of such a device, is necessary for reasons which shall include, but not be limited
196	196	167to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the
197	197	168condition of the device or in a part of the device; or (iii) the condition of the device, or the part of
198	198	169the devices requires repairs and the cost of such repairs would be more than sixty percent of the
199	199	170cost of a replacement device or of the part being replaced.
200	200	171 Confirmation from a prescribing health care provider may be required if the prosthetic or
201	201	172custom orthotic device or part being replaced is less than three years old.
202	202	173 SECTION 8. Section 8AA of chapter 176A of the General Laws, as so appearing, is
203	203	174hereby amended by striking out subsection (b) and inserting in place thereof the following
204	204	175subsection:-
205	205	176 (b) For the purposes of this section the following words shall, unless the context clearly
206	206	177requires otherwise, have the following meanings:
207	207	178 “Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body,
208	208	179which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
209	209	180appropriately used in a person’s home or any setting in which normal life activities take place in
210	210	181the community.
211	211	182 “Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg
212	212	183including a device that is designed specifically for physical activities . 10 of 15
213	213	184 SECTION 9. Subsection (f) of said section 8AA of said chapter 176A of the General
214	214	185Laws, as so appearing, is hereby amended by inserting after the word “devices” the following
215	215	186words:- but must do so in a nondiscriminatory manner and shall not deny coverage for
216	216	187habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an
217	217	188insured’s actual or perceived disability.
218	218	189 SECTION 10. Said section 8AA of said chapter 176A, as so appearing, is hereby further
219	219	190amended by adding the following subsection:-
220	220	191 (h) Any such contract shall be required to provide coverage for prosthetic devices and
221	221	192orthotic devices for daily use in addition to those designed, custom-built or fitted for a specific
222	222	193enrollee for the performance of physical activities, as applicable, to maximize the enrollee’s
223	223	194ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage
224	224	195required pursuant to this subsection shall include the repair or replacement of a prosthetic or
225	225	196orthotic device for the performance of physical activities.
226	226	197 SECTION 11. Section 4AA of chapter 176B of the General Laws, as so appearing, is
227	227	198hereby amended by striking out subsection (b) and inserting in place thereof the following
228	228	199subsection:-
229	229	200 (b) For the purposes of this section the following words shall, unless the context clearly
230	230	201requires otherwise, have the following meanings:
231	231	202 “Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body,
232	232	203which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
233	233	204appropriately used in a person’s home or any setting in which normal life activities take place in
234	234	205the community. 11 of 15
235	235	206 “Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg
236	236	207including a device that is designed specifically for physical activities.
237	237	208 SECTION 12. Subsection (f) of said section 4AA of said chapter 176B, as so appearing,
238	238	209is hereby amended by amended by inserting after the word “devices” the following words:-but
239	239	210must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or
240	240	211rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s
241	241	212actual or perceived disability.
242	242	213 SECTION 13. Said section 4AA of said chapter 176B, as so appearing, is hereby further
243	243	214amended by adding the following subsection:-
244	244	215 (h) Any such certificate shall be required to provide coverage for prosthetic devices and
245	245	216orthotic devices for daily use in addition to those designed, custom-built or fitted for a specific
246	246	217enrollee for the performance of physical activities, as applicable, to maximize the enrollee’s
247	247	218ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage
248	248	219required pursuant to this subsection shall include the repair or replacement of a prosthetic or
249	249	220orthotic device for the performance of physical activities.
250	250	221 (h)(1): The division shall consider these benefits habilitative or rehabilitative for purposes
251	251	222of any state or federal requirement for coverage of essential health benefits.
252	252	223 (h)(2): An insurer shall render utilization determinations in a nondiscriminatory manner
253	253	224and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or
254	254	225orthotics, solely on the basis of an insured’s actual or perceived disability. 12 of 15
255	255	226 (h)(3): An insurer shall not deny a prosthetic or orthotic benefit for an individual with
256	256	227limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
257	257	228or surgical intervention to restore or maintain the ability to perform the same physical activity.
258	258	229 (h)(4): Prosthetic and custom orthotic device coverage shall not be subject to separate
259	259	230financial requirements that are applicable only with respect to that coverage, An individual
260	260	231health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any
261	261	232cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
262	262	233applicable to the plan’s coverage for inpatient physician and surgical services.
263	263	234 (h)(5): A health plan that provides coverage for prosthetic or orthotic services shall
264	264	235ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices
265	265	236and technology from not less than two distinct prosthetic and custom orthotic providers in the
266	266	237managed care plan’s provider network located in the state. In the event that medically necessary
267	267	238covered orthotics and prosthetics are not available from an in-network provider, the insurer shall
268	268	239provide processes to refer a member to an out-of-network provider and shall fully reimburse the
269	269	240out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on
270	270	241an in-network basis.
271	271	242 (h)(6): If coverage for prosthetic or custom orthotic devices is provided, payment shall be
272	272	243made for the replacement of a prosthetic or custom orthotic device or for the replacement of any
273	273	244part of such devices, without regard to continuous use or useful lifetime restrictions, if an
274	274	245ordering health care provider determines that the provision of a replacement device, or a
275	275	246replacement part of such a device, is necessary for reasons which shall include, but not be limited
276	276	247to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the 13 of 15
277	277	248condition of the device or in a part of the device; or (iii) the condition of the device, or the part of
278	278	249the devices requires repairs and the cost of such repairs would be more than sixty percent of the
279	279	250cost of a replacement device or of the part being replaced.
280	280	251 Confirmation from a prescribing health care provider may be required if the prosthetic or
281	281	252custom orthotic device or part being replaced is less than three years old.
282	282	253 SECTION 14. Section 4S of chapter 176G of the General Laws, as so appearing, is
283	283	254hereby amended by striking out subsection (b) and inserting in place thereof the following
284	284	255subsection:-
285	285	256 (b) For the purposes of this section the following words shall, unless the context clearly
286	286	257requires otherwise, have the following meanings:
287	287	258 “Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body,
288	288	259which may be used to eliminate, control or assist motion at a joint or body part; and (ii)
289	289	260appropriately used in a person’s home or any setting in which normal life activities take place in
290	290	261the community.
291	291	262 “Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg
292	292	263including a device that is designed specifically for physical activities.
293	293	264 SECTION 15. Subsection (f) of section 4S of said chapter 176G of the General Laws, as
294	294	265so appearing, is hereby amended by inserting after the word “devices” the following words:-but
295	295	266must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or
296	296	267rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s
297	297	268actual or perceived disability. 14 of 15
298	298	269 SECTION 16. Said section 4S of said chapter 176G, as so appearing, is hereby further
299	299	270amended by adding the following subsection:-
300	300	271 (h)(1) A health maintenance contract shall be required to provide coverage for prosthetic
301	301	272devices and orthotic devices for daily use in addition to those designed, custom-built or fitted for
302	302	273a specific enrollee for the performance of physical activities, as applicable, to maximize the
303	303	274enrollee’s ability to ambulate, run, bike and swim and to maximize upper limb function. The
304	304	275coverage required pursuant to this subsection shall include the repair or replacement of a
305	305	276prosthetic or orthotic device for the performance of physical activities.
306	306	277 (h)(2): The division shall consider these benefits habilitative or rehabilitative for purposes
307	307	278of any state or federal requirement for coverage of essential health benefits.
308	308	279 (h)(3): An insurer shall render utilization determinations in a nondiscriminatory manner
309	309	280and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or
310	310	281orthotics, solely on the basis of an insured’s actual or perceived disability.
311	311	282 (h)(4): An insurer shall not deny a prosthetic or orthotic benefit for an individual with
312	312	283limb loss or absence that would otherwise be covered for a non-disabled person seeking medical
313	313	284or surgical intervention to restore or maintain the ability to perform the same physical activity.
314	314	285 (h)(5): Prosthetic and custom orthotic device coverage shall not be subject to separate
315	315	286financial requirements that are applicable only with respect to that coverage, An individual
316	316	287health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any
317	317	288cost-sharing requirements shall not be more restrictive than the cost-sharing requirements
318	318	289applicable to the plan’s coverage for inpatient physician and surgical services. 15 of 15
319	319	290 (h)(6): A health plan that provides coverage for prosthetic or orthotic services shall
320	320	291ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices
321	321	292and technology from not less than two distinct prosthetic and custom orthotic providers in the
322	322	293managed care plan’s provider network located in the state. In the event that medically necessary
323	323	294covered orthotics and prosthetics are not available from an in-network provider, the insurer shall
324	324	295provide processes to refer a member to an out-of-network provider and shall fully reimburse the
325	325	296out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on
326	326	297an in-network basis.
327	327	298 (h)(7): If coverage for prosthetic or custom orthotic devices is provided, payment shall be
328	328	299made for the replacement of a prosthetic or custom orthotic device or for the replacement of any
329	329	300part of such devices, without regard to continuous use or useful lifetime restrictions, if an
330	330	301ordering health care provider determines that the provision of a replacement device, or a
331	331	302replacement part of such a device, is necessary for reasons which shall include, but not be limited
332	332	303to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the
333	333	304condition of the device or in a part of the device; or (iii) the condition of the device, or the part of
334	334	305the devices requires repairs and the cost of such repairs would be more than sixty percent of the
335	335	306cost of a replacement device or of the part being replaced.
336	336	307 Confirmation from a prescribing health care provider may be required if the prosthetic or
337	337	308custom orthotic device or part being replaced is less than three years old.