Mass. bill filed to expand prosthetic and orthotic coverage for people with limb loss

Representative Carlos González of Springfield filed House Docket No. 3787, "An Act to improve outcomes for persons with limb loss and limb difference," with the House on Jan. 17, 2025. The filing seeks to amend multiple sections of the Massachusetts General Laws to expand insurance and MassHealth coverage for prosthetic and orthotic devices.

The bill adds and amends definitions of “orthosis” and “prosthetic device” across several chapters and sections of state law, and directs that coverage include not only primary daily-use devices but also prosthetics and orthotics custom-built or fitted for specific enrollees to perform physical activities. The text expressly lists activities and uses such as ambulation, running, biking, swimming and devices designed for showering and bathing, and it requires coverage for repair or replacement of such devices.

The measure requires that insurers treat these benefits as habilitative or rehabilitative when applicable to state or federal essential-health-benefit requirements and prohibits insurers from denying habilitative or rehabilitative benefits — including prosthetics or orthotics — solely on the basis of an insured’s actual or perceived disability. It also states that coverage for prosthetic and custom orthotic devices must not be subject to separate financial requirements that apply only to that coverage; any cost-sharing must not be more restrictive than the plan’s cost-sharing for inpatient physician and surgical services.

To ensure access, the bill requires that a health plan offering prosthetic or orthotic services provide medically necessary care and devices from at least two distinct in-state prosthetic and orthotic providers in the plan’s network. If medically necessary services are not available from an in-network provider, the insurer must provide a process to refer members to an out-of-network provider and fully reimburse that provider at a mutually agreed rate less member cost-sharing determined on an in‑network basis.

Replacement and repair rules in the text require payment for replacement of a prosthetic or custom orthotic device or any part of such a device without regard to continuous-use or useful-lifetime restrictions if an ordering health-care provider determines replacement is necessary. Specified reasons include a change in the patient’s physiological condition, an irreparable change in the device, or when repair costs exceed 60 percent of the cost of a replacement device or part. The bill allows a prescribing provider to be required to confirm replacement requests when the device or part being replaced is less than three years old.

For MassHealth members, the bill adds a new statutory section specifying that coverage for prosthetic and orthotic devices — including repair or replacement — be provided under the same terms and conditions that apply to other durable medical equipment. The MassHealth provision also requires a written prescription on the prescriber’s form that includes the member’s name and address, MassHealth identification number, specific identification of the prescribed item, medical justification including diagnosis, the prescriber’s contact information and the signature date.

The filing amends multiple statutory provisions in chapters 32A (section 17I), 118E (new section 10R), 175 (section 47Z), 176A (section 8AA), 176B (section 4AA), and 176G (section 4S) of the General Laws to implement the changes. The petitioners listed in the filing include Carlos González (10th Hampden; filed Jan. 17, 2025), Joanne M. Comerford (Hampshire, Franklin and Worcester; added Jan. 27, 2025) and Jacob R. Oliveira (Hampden, Hampshire and Worcester; added Feb. 7, 2025).

The document indicates the bill was filed in the House and assigned to Financial Services. The filing itself records statutory text and procedural details but does not record committee action, a floor vote or enactment.