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