Bill
H 4162
Expands Massachusetts coverage for ostomy/fistula supplies and standardizes reimbursement at Medicare rates to ensure continuous ostomy care.
Status & procedural notes
- Bill number: H 4162 (House) — filed 01/16/2025, presented by Rep. Rob Consalvo.
- Introduced/read first time: 03/06/2025; referred to Committee on Judiciary (03/06/2025) and later to Committee on Financial Services (05/29/2025). Senate concurred 06/02/2025. Hearing scheduled 09/17/2025. Related bill: HD 2829 (replaces).
- Note: the materials provided also include an unrelated draft South Carolina amendment (changes to the definition of “anything of value” in S.C. Code §8‑13‑100). That South Carolina text is not part of H 4162 (Massachusetts) and appears to be included in error.
Purpose / intent
- To expand and standardize access to medically necessary ostomy and fistula supplies and care in Massachusetts, improve continuity of care during insurance transitions, ensure adequate reimbursement to suppliers, and require hospitals to provide certified ostomy care and outpatient follow-up.
Key provisions (by statutory change)
- Chapter 32A (Group Insurance Commission): adds Section 17X requiring the GIC to cover all medical supplies for management of surgically created or spontaneous fistulas and ostomy-related supplies; prohibits requiring non‑medical supplies as a condition of coverage; requires public disclosure of coverage policies; requires transfer of ostomy care information to a new insurer within 72 hours and prohibits shipping delays during insurer transitions; mandates payer reimbursement to suppliers at no less than the Medicare rate.
Chapter 111 (Hospitals): adds Section 51N requiring any acute‑care hospital that performs ostomy surgery to employ or have access to certified ostomy‑care specialists and to provide appropriate outpatient follow‑up.
Chapter 112 (Physicians): adds Section 12D½ specifying that prescriptions for ostomy supplies issued in MA are valid for at least one year; allows physicians to prescribe quantities beyond statutory/insurance limits when medically necessary; forbids delays in fulfillment from approval/appeal processes; requires suppliers to give patients and prescribers 1 month advance notice of prescription expirations and of intended brand/product substitutions (non‑medical switching). Substitution notices must include samples; patients who find substitutes inferior may return to prior products or receive an equivalent.
Chapter 118E (MassHealth/Medicaid): adds Section 10X requiring MassHealth and its contractors to cover ostomy/fistula supplies with rules mirroring those above (72‑hour transfer, Medicare‑rate reimbursement, 1‑month notices, dispensed as written).
Chapter 175 (Commercial insurance): adds Section 47AAA requiring all policies considered creditable coverage to cover ostomy/fistula supplies and related complications; prohibits mandatory use of non‑medical supplies; includes same continuity, notice, and public‑disclosure requirements.
Who is affected
- Primary beneficiaries: patients with ostomies or surgically created/spontaneous fistulas (including those with ostomy‑related complications).
- Providers: physicians prescribing ostomy supplies, certified ostomy nurses/specialists, acute‑care hospitals performing ostomy surgery.
- Suppliers and durable medical equipment (DME) vendors: must comply with notice, substitution, and reimbursement provisions.
- Payers: Group Insurance Commission, MassHealth/Medicaid plans, private insurers and third‑party administrators — will have new coverage, continuity, and reimbursement obligations.
Potential impacts
- Patient care: increased continuity of care, fewer disruptions in supply access, and better matching of supplies to individual needs.
- Financial: minimum reimbursement tied to Medicare rates may increase supplier payments; insurers may face higher short‑term costs offset by improved outcomes and reduced complications. Hospitals may incur costs to ensure certified ostomy specialists are available.
- Administrative: insurers and suppliers must implement 72‑hour transfer processes, 1‑month notice systems, and public disclosure of coverage policies.
Effective dates / timing
- The bill text does not specify phased implementation dates; provisions would take effect according to regular enactment procedures unless the bill specifies otherwise in final language.
For further review
- Text sections to inspect for implementation details: proposed Sections 17X (Ch. 32A), 51N (Ch. 111), 12D½ (Ch. 112), 10X (Ch. 118E), and 47AAA (Ch. 175).
Compiled from official sources — confirm details with the bill’s official record.
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