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SD 1134

An Act to improve outcomes for those with limb loss and limb difference

194th Legislature (2025-2026) Introduced by Jake Oliveira

The bill requires nondiscriminatory, expanded coverage for prosthetic and orthotic devices, including activity-specific options and repairs, with access to in-state providers and r

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Bill Summary · SD 1134

Summary: Massachusetts Senate Bill SD 1134 — An Act to improve outcomes for those with limb loss and limb difference

Purpose and intent

This bill seeks to ensure comprehensive, nondiscriminatory coverage for prosthetic and orthotic devices for MassHealth members and to clarify coverage under private plans. It aims to improve functional outcomes for individuals with limb loss or limb difference by expanding the types of devices covered, reducing barriers to access, and aligning benefits with habilitative/rehabilitative needs.

Key provisions

  • Definitions and scope

    • Replaces or updates definitions of “orthosis” and “prosthetic device” to cover devices used to support, align, or enhance motion, including those used at home or in community settings, and devices designed for specific physical activities.

  • Non-discrimination and habilitative/rehabilitative benefits (new language)

    • Insurers must provide coverage in a nondiscriminatory manner.
    • Benefits related to prosthetics and orthotics must be treated as habilitative/rehabilitative where appropriate and not denied solely due to disability.

  • Expanded coverage for activity-specific devices (Section 3(g))

    • Requires coverage for prosthetic/orthotic devices designed for specific activities (e.g., ambulation, running, biking, swimming) and for devices designed for showering/bathing.
    • Coverage includes repair or replacement necessary for these devices.

  • Utilization decisions and access (Section 3(h))

    • Insurers must process determinations nondiscriminately.
    • No denial of prosthetic/orthotic benefits for limb loss when such benefits would be covered for non-disabled individuals seeking similar activities.
    • Cost-sharing for prosthetics/orthotics cannot be more restrictive than that for inpatient physician and surgical services.

  • Provider network and access (Section 3(h)(5))

    • Plans must ensure access to at least two in-state, in-network prosthetic/orthotic providers.
    • If in-network options are unavailable, plans must refer to out-of-network providers and reimburse at a mutually agreed rate, with cost-sharing aligned to in-network levels.

  • Replacement and repair triggers (Section 3(h)(6))

    • Coverage must include replacement or replacement parts without lifetime-use restrictions when certain conditions apply (physiological change, irreparable device damage, or repairs exceeding 60% of replacement cost).
    • Prescriber confirmation may be required if the device is under three years old.

  • MassHealth integration (Section 4; new Section 10R)

    • MassHealth must cover prosthetic and orthotic devices, including repairs/replacements, under the same terms as other durable medical equipment.
    • Benefits are treated as habilitative/rehabilitative where applicable; nondiscrimination provisions apply; access and utilization protections mirror those in other coverage.

Who would be affected

  • MassHealth members who use prosthetic and orthotic devices.
  • Private health plans and insurers that administer prosthetic/orthotic benefits.
  • In-state prosthetic and orthotic providers and networks.
  • Enrollees seeking devices for enhanced daily activity and athletic activities.

Implementation and timeline

The bill as introduced would require regulatory and contractual changes across MassHealth and private plans. Specific effective dates are not stated in the text provided; passage would likely trigger phased rulemaking and network adequacy reviews.

Compiled from official sources — confirm details with the bill’s official record.

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