Mass. bill would require insurers and MassHealth to cover prosthetic and orthotic devices, including activity-specific equipment

A bill filed in the Massachusetts House on Sept. 19, 2025, would require state-regulated health plans and MassHealth to cover prosthetic and orthotic devices, including devices custom-built or fitted for physical activities, and would prohibit denials of such coverage based solely on an insured’s actual or perceived disability, according to House Bill No. 4549.

The bill, titled "An Act to improve outcomes for persons with limb loss and limb difference," was reported to the House by the Financial Services Committee on Sept. 29, 2025, with the committee recommending that the accompanying bill (House No. 4549) ought to pass; the committee report is signed "For the committee, James M. Murphy." The bill was filed Sept. 19, 2025 as House No. 4549 and is associated with a petition and an earlier bill reference (House No. 1178) in the committee report.

Why it matters: The proposal would change statutory coverage standards across multiple chapters of the General Laws, affecting private insurer contracts, certificates, health maintenance contracts and MassHealth policies. If enacted, the law would require parity in coverage rules and provider access for prosthetic and custom orthotic devices and could affect coverage determinations, network adequacy and replacement practices.

Key provisions

Definitions: The bill adds or amends statutory definitions to clarify that an "orthosis" is a device used to support, align, correct or prevent deformities of the body and that a "prosthetic device" is an artificial limb to replace, in whole or in part, an arm or leg, explicitly noting inclusion of devices designed for physical activities.

Nondiscrimination and utilization: Multiple statutory sections are amended to require insurers and the division that administers MassHealth to render utilization determinations in a nondiscriminatory manner and to prohibit denial of habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.

Activity-specific devices and daily-use coverage: In addition to primary daily-use devices, the bill requires coverage for prosthetic and orthotic devices that are custom-built or fitted for an enrollee for the performance of physical activities (the text lists examples including ambulating, running, biking, swimming and devices specifically designed for showering and bathing). Coverage for repair or replacement of such devices is included.

Replacement, repair and confirmation rules: The bill directs payment for replacement of a prosthetic or custom orthotic device or any of its parts "without regard to continuous use or useful lifetime restrictions" when an ordering health care provider determines replacement is necessary. Replacement reasons explicitly include a change in the patient's physiological condition, an irreparable change in the condition of the device or when repair costs would exceed 60 percent of the cost of replacement. The text permits confirmation from a prescribing health care provider when the device or part being replaced is less than three years old.

Cost-sharing and parity: The bill states that prosthetic and custom orthotic device coverage shall not be subject to separate financial requirements applicable only to that coverage; an individual health plan may impose cost-sharing but only to the extent that such cost-sharing is no more restrictive than the plan’s cost-sharing for inpatient physician and surgical services.

Provider access and out-of-network reimbursement: A health plan that provides prosthetic or orthotic services must ensure access to medically necessary care from not fewer than two distinct prosthetic and custom orthotic providers in the managed care plan’s in-state network. If medically necessary covered orthotics and prosthetics are not available from an in-network provider, insurers must provide processes to refer a member to an out-of-network provider and fully reimburse the out‑of‑network provider at a mutually agreed rate, with member cost-sharing determined on an in-network basis.

Statutory changes: The bill makes parallel changes across several statutory chapters and sections, including amendments to chapter 32A §17I, the insertion of section 10AA in chapter 118E (MassHealth), and amendments to chapter 175 §47Z, chapter 176A §8AA, chapter 176B §4AA, and chapter 176G §4S. The changes consistently address definitions, nondiscrimination, activity-specific coverage, replacement rules, provider access and cost-sharing parity.

Committee action and next steps: The Financial Services Committee reported that the accompanying bill ought to pass; the committee report is dated and signed. That committee recommendation is not the same as final legislative passage. The bill must still proceed through the legislative process—committee reports, floor votes in both chambers and the governor’s signature—before becoming law.

What the bill does not specify or leaves to later rules

The bill sets statutory standards but leaves implementation details to insurers, the MassHealth division and implementing regulations. For example, the bill requires a minimum of two in-state provider options but does not specify geographic distribution or timeline for network changes. The bill allows insurers to impose cost-sharing provided it is no more restrictive than inpatient physician and surgical services but does not set exact cost-sharing amounts.

Provenance

This summary is based on the text of House Bill No. 4549 (filed 9/19/2025) and the committee report appearing on the bill cover sheet and introductory pages of the document.