H1178

	SECTION 1. Section 17I of chapter 32A of the General Laws, as so appearing in the 2022 Official Edition, is hereby amended by striking out subsection (b) and inserting in place thereof the following subsection:-
	(b) For the purposes of this section the following words shall, unless the context clearly requires otherwise, have the following meanings:
	“Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii) appropriately used in a person’s home or any setting in which normal life activities take place in the community.
	“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg including a device that is designed specifically for physical activities.
	SECTION 2. Subsection (f) of said section 17I of said chapter 32A of the General Laws, as so appearing, is hereby amended by inserting after the word “devices” the following words:- 
	but must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	SECTION 3. Said section 17I of said chapter 32A, as so appearing, is hereby further amended by adding the following subsections:-
	(g) In addition to primary prosthetic and orthotic devices for daily use, the commission shall provide coverage for prosthetic devices and orthotic devices designed, custom-built or fitted for a specific enrollee for the performance of physical activities, including devices specifically designed for showering and bathing, as applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage required pursuant to this subsection shall include the repair or replacement of a prosthetic or orthotic device for the performance of physical activities.
	(h)(1) The division shall consider these benefits habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.
	(2) An insurer shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	(3) An insurer shall not deny a prosthetic or orthotic benefit for an individual with limb loss or absence that would otherwise be covered for a non-disabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
	(4) Prosthetic and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage, An individual health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any cost-sharing requirements shall not be more restrictive than the cost-sharing requirements applicable to the plan’s coverage for inpatient physician and surgical services.
	(5) A health plan that provides coverage for prosthetic or orthotic services shall ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices and technology from not less than two distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the state. In the event that medically necessary covered orthotics and prosthetics are not available from an in-network provider, the insurer shall provide processes to refer a member to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on an in-network basis.
	(6) If coverage for prosthetic or custom orthotic devices is provided, payment shall be made for the replacement of a prosthetic or custom orthotic device or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary for reasons which shall include, but not be limited to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the condition of the device or in a part of the device; or (iii) the condition of the device, or the part of the devices requires repairs and the cost of such repairs would be more than sixty percent of the cost of a replacement device or of the part being replaced.
	Confirmation from a prescribing health care provider may be required if the prosthetic or custom orthotic device or part being replaced is less than three years old.
	SECTION 4. Chapter 118E of the General Laws, as so appearing, is hereby amended by inserting after section 10Q the following section:-
	Section 10R. (a) For the purposes of this section the following words shall, unless the context clearly requires otherwise, have the following meanings:
	“Orthotic device”, a device: (i) used to support, align, correct or prevent deformities of the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii) appropriately used in a person’s home or any setting in which normal life activities take place in the community.
	“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg including a device that is designed specifically for physical activities.
	(b)(1) The division shall provide coverage for prosthetic and orthotic devices including the repair or replacement of prosthetic or orthotic devices to eligible MassHealth members under the same terms and conditions that apply to other durable medical equipment. The coverage required by this section shall be subject to the terms and conditions applicable to other benefits.
	(2) The division shall consider these benefits habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.
	(3) An insurer shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	(4) An insurer shall not deny a prosthetic or orthotic benefit for an individual with limb loss or absence that would otherwise be covered for a non-disabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
	(5) Prosthetic and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage, An individual health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any cost-sharing requirements shall not be more restrictive than the cost-sharing requirements applicable to the plan’s coverage for inpatient physician and surgical services.
	(6) A health plan that provides coverage for prosthetic or orthotic services shall ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices and technology from not less than two distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the state. In the event that medically necessary covered orthotics and prosthetics are not available from an in-network provider, the insurer shall provide processes to refer a member to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on an in-network basis.
	(7) If coverage for prosthetic or custom orthotic devices is provided, payment shall be made for the replacement of a prosthetic or custom orthotic device or for the replacement of ant part of such devices, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary for reasons which shall include, but not be limited to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the condition of the device or in a part of the device; or (iii) the condition of the device, or the part of the devices requires repairs and the cost of such repairs would be more than sixty percent of the cost of a replacement device or of the part being replaced.
	Confirmation from a prescribing health care provider may be required if the prosthetic or custom orthotic device or part being replaced is less than three years old.
	(c) In addition to primary prosthetic and orthotic devices for daily use, the division shall provide coverage for prosthetic devices and orthotic devices custom-built or fitted for a specific enrollee, for the performance of physical activities including devices specifically designed for showering and bathing, as applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage required pursuant to this subsection shall include the repair or replacement of a prosthetic or orthotic device for the performance of physical activities.
	(d) Eligible MassHealth members shall be required to provide a written prescription signed by a licensed physician or an independent nurse practitioner. The prescription must be written on the prescriber's prescription form and must include the following information:(i) the member's name and address; (ii) the member’s MassHealth identification number; (iii) specific identification of the prescribed item; (iv) medical justification for the use of the item, including the member’s diagnosis; (v) the prescriber's address and telephone number; and (vi) the date on which the prescription was signed by the prescriber.
	SECTION 5. Section 47Z of chapter 175 of the General Laws, as so appearing, is hereby amended by striking out subsection (b) and inserting in place thereof the following subsection:-
	(b) For the purposes of this section the following words shall, unless the context clearly requires otherwise, have the following meanings:
	“Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii) appropriately used in a person’s home or any setting in which normal life activities take place in the community.
	“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg including a device that is designed specifically for physical activities.
	SECTION 6. Subsection (f) of said section 47Z of said chapter 175 of the General Laws, as so appearing, is hereby amended by inserting after the word “devices” the following words:- 
	but must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	SECTION 7. Said section 47Z of said chapter 175, as so appearing, is hereby further amended by adding the following subsection:-
	(h)(1) Any such policy shall provide coverage for prosthetic devices and orthoses for daily use, in addition to prosthetic devices and orthoses designed, custom-built or fitted for a specific enrollee for the performance of physical activities, as applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage required pursuant to this subsection shall include the repair or replacement of a prosthetic or orthotic device for the performance of physical activities.
	(2) The division shall consider these benefits habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.
	(3) An insurer shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	(4) An insurer shall not deny a prosthetic or orthotic benefit for an individual with limb loss or absence that would otherwise be covered for a non-disabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
	(5) Prosthetic and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage, An individual health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any cost-sharing requirements shall not be more restrictive than the cost-sharing requirements applicable to the plan’s coverage for inpatient physician and surgical services.
	(6) A health plan that provides coverage for prosthetic or orthotic services shall ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices and technology from not less than two distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the state. In the event that medically necessary covered orthotics and prosthetics are not available from an in-network provider, the insurer shall provide processes to refer a member to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on an in-network basis.
	(7) If coverage for prosthetic or custom orthotic devices is provided, payment shall be made for the replacement of a prosthetic or custom orthotic device or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary for reasons which shall include, but not be limited to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the condition of the device or in a part of the device; or (iii) the condition of the device, or the part of the devices requires repairs and the cost of such repairs would be more than sixty percent of the cost of a replacement device or of the part being replaced.
	Confirmation from a prescribing health care provider may be required if the prosthetic or custom orthotic device or part being replaced is less than three years old.
	SECTION 8. Section 8AA of chapter 176A of the General Laws, as so appearing, is hereby amended by striking out subsection (b) and inserting in place thereof the following subsection:-
	(b) For the purposes of this section the following words shall, unless the context clearly requires otherwise, have the following meanings:
	“Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii) appropriately used in a person’s home or any setting in which normal life activities take place in the community.
	“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg including a device that is designed specifically for physical activities .
	SECTION 9. Subsection (f) of said section 8AA of said chapter 176A of the General Laws, as so appearing, is hereby amended by inserting after the word “devices” the following words:- 
	but must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	SECTION 10. Said section 8AA of said chapter 176A, as so appearing, is hereby further amended by adding the following subsection:-
	(h) Any such contract shall be required to provide coverage for prosthetic devices and orthotic devices for daily use in addition to those designed, custom-built or fitted for a specific enrollee for the performance of physical activities, as applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage required pursuant to this subsection shall include the repair or replacement of a prosthetic or orthotic device for the performance of physical activities.
	SECTION 11. Section 4AA of chapter 176B of the General Laws, as so appearing, is hereby amended by striking out subsection (b) and inserting in place thereof the following subsection:-
	(b) For the purposes of this section the following words shall, unless the context clearly requires otherwise, have the following meanings:
	“Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii) appropriately used in a person’s home or any setting in which normal life activities take place in the community.
	“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg including a device that is designed specifically for physical activities.
	SECTION 12. Subsection (f) of said section 4AA of said chapter 176B, as so appearing, is hereby amended by amended by inserting after the word “devices” the following words:-
	but must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	SECTION 13. Said section 4AA of said chapter 176B, as so appearing, is hereby further amended by adding the following subsection:-
	(h)(1) Any such certificate shall be required to provide coverage for prosthetic devices and orthotic devices for daily use in addition to those designed, custom-built or fitted for a specific enrollee for the performance of physical activities, as applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage required pursuant to this subsection shall include the repair or replacement of a prosthetic or orthotic device for the performance of physical activities.
	(2) The division shall consider these benefits habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.
	(3) An insurer shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	(4) An insurer shall not deny a prosthetic or orthotic benefit for an individual with limb loss or absence that would otherwise be covered for a non-disabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
	(5) Prosthetic and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage, An individual health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any cost-sharing requirements shall not be more restrictive than the cost-sharing requirements applicable to the plan’s coverage for inpatient physician and surgical services.
	(6) A health plan that provides coverage for prosthetic or orthotic services shall ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices and technology from not less than two distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the state. In the event that medically necessary covered orthotics and prosthetics are not available from an in-network provider, the insurer shall provide processes to refer a member to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on an in-network basis.
	(7) If coverage for prosthetic or custom orthotic devices is provided, payment shall be made for the replacement of a prosthetic or custom orthotic device or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary for reasons which shall include, but not be limited to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the condition of the device or in a part of the device; or (iii) the condition of the device, or the part of the devices requires repairs and the cost of such repairs would be more than sixty percent of the cost of a replacement device or of the part being replaced.
	Confirmation from a prescribing health care provider may be required if the prosthetic or custom orthotic device or part being replaced is less than three years old.
	SECTION 14. Section 4S of chapter 176G of the General Laws, as so appearing, is hereby amended by striking out subsection (b) and inserting in place thereof the following subsection:-
	(b) For the purposes of this section the following words shall, unless the context clearly requires otherwise, have the following meanings:
	“Orthosis”, a device: (i) used to support, align, correct or prevent deformities of the body, which may be used to eliminate, control or assist motion at a joint or body part; and (ii) appropriately used in a person’s home or any setting in which normal life activities take place in the community.
	“Prosthetic device”, an artificial limb device to replace, in whole or in part, an arm or leg including a device that is designed specifically for physical activities.
	SECTION 15. Subsection (f) of section 4S of said chapter 176G of the General Laws, as so appearing, is hereby amended by inserting after the word “devices” the following words:-
	but must do so in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	SECTION 16. Said section 4S of said chapter 176G, as so appearing, is hereby further amended by adding the following subsection:-
	(h)(1) A health maintenance contract shall be required to provide coverage for prosthetic devices and orthotic devices for daily use in addition to those designed, custom-built or fitted for a specific enrollee for the performance of physical activities, as applicable, to maximize the enrollee’s ability to ambulate, run, bike and swim and to maximize upper limb function. The coverage required pursuant to this subsection shall include the repair or replacement of a prosthetic or orthotic device for the performance of physical activities.
	(2) The division shall consider these benefits habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.
	(3) An insurer shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetics or orthotics, solely on the basis of an insured’s actual or perceived disability.
	(4) An insurer shall not deny a prosthetic or orthotic benefit for an individual with limb loss or absence that would otherwise be covered for a non-disabled person seeking medical or surgical intervention to restore or maintain the ability to perform the same physical activity.
	(5) Prosthetic and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage, An individual health plan may impose cost-sharing on prosthetic or custom orthotic devices provided that any cost-sharing requirements shall not be more restrictive than the cost-sharing requirements applicable to the plan’s coverage for inpatient physician and surgical services.
	(6) A health plan that provides coverage for prosthetic or orthotic services shall ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices and technology from not less than two distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the state. In the event that medically necessary covered orthotics and prosthetics are not available from an in-network provider, the insurer shall provide processes to refer a member to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less member cost-sharing determined on an in-network basis.
	(7) If coverage for prosthetic or custom orthotic devices is provided, payment shall be made for the replacement of a prosthetic or custom orthotic device or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that the provision of a replacement device, or a replacement part of such a device, is necessary for reasons which shall include, but not be limited to: (i) a change in the physiological condition of the patient; (ii) an irreparable change in the condition of the device or in a part of the device; or (iii) the condition of the device, or the part of the devices requires repairs and the cost of such repairs would be more than sixty percent of the cost of a replacement device or of the part being replaced.
	Confirmation from a prescribing health care provider may be required if the prosthetic or custom orthotic device or part being replaced is less than three years old.