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Bill

S 811

Relates to the collection of certain demographic information by certain state agencies, boards, departments and commissions

2025 Regular Session Introduced by Mike Gianaris

Implements nondiscriminatory coverage for prosthetic/orthotic devices, expands in-network access, and ensures timely replacement and habilitative/rehabilitative benefits.

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Bill Summary · S 811

Summary of Senate Bill S.811: An Act to improve outcomes for those with limb loss and limb difference

Overview

  • Bill number & short title: S.811, An Act to improve outcomes for those with limb loss and limb difference.
  • Introduced: February 27, 2025.
  • Status: Referred to Senate Ways and Means after being reported favorably by the committee. Previously recommended ought to pass by the committee on Nov. 17, 2025; also linked to prior committee action in Health Care Financing and Financial Services.
  • Jurisdiction: Massachusetts General Laws amendments impacting private health plans and MassHealth (Massachusetts’ Medicaid program).

What the bill would do (highlights)

  • The bill imposes nondiscriminatory coverage requirements for prosthetic and orthotic devices and related services, expanding access and clarifying obligations for insurers and MassHealth.
  • It requires broader coverage for devices designed for daily use and for specific activities (e.g., devices designed for showering/bathing, running, biking, swimming) to maximize mobility and function.
  • It expands protections around habilitative/rehabilitative benefits, ensuring prosthetics and orthotics are covered without discrimination based on disability status.
  • It sets access, cost-sharing, and network requirements intended to improve timely and comprehensive access to prosthetic and orthotic care.

Key provisions and changes (by topic)

Definitions

  • Adds explicit definitions for:
    • “Orthosis” (devices to support, align, correct, or prevent deformities; intended for use in home or community settings).
    • “Prosthetic device” (artificial limb, including devices designed for physical activity).

Coverage and benefits (general)

  • Coverage for prosthetic and orthotic devices includes repair or replacement for devices used to perform physical activities.
  • Coverage is to be treated as habilitative/rehabilitative where applicable, aligning with essential health benefits.

Non-discrimination and utilization

  • Insurers must operate in a nondiscriminatory manner, not denying prosthetic/orthotic benefits based on actual or perceived disability.
  • Providers must determine utilization without discriminatory barriers.

In-network access and out-of-network procedures

  • Health plans must ensure access to at least two distinct prosthetic/orthotic providers within the plan’s network in Massachusetts.
  • If in-network coverage is unavailable, plans must offer referral to out-of-network providers and fully reimburse at a mutually agreed rate, with member cost-sharing calculated on an in-network basis.

Replacement and ongoing care

  • Payment for replacement or replacement parts must not be restricted by arbitrary “useful lifetime” limits if:
    • There is a change in the patient’s physiological condition, or
    • The device/part is irreparably damaged, or
    • Repair costs would exceed 60% of the replacement cost.
  • If the device replacement is less than three years old, prescribing-provider confirmation may be required.

MassHealth (Massachusetts Medicaid) specifics

  • Adds a new Section 10R to Chapter 118E:
    • MassHealth must cover prosthetic and orthotic devices (including repair and replacement) under the same terms as other durable medical equipment.
    • Coverage is treated as habilitative/rehabilitative for essential health benefits purposes.
    • Nondiscrimination in utilization determinations and coverage for prosthetics/orthotics.

Procedural and timeline aspects

  • Hearing/Committee activity: Hearing scheduled (e.g., June 24, 2025) with committee actions leading to favorable reporting and referral to Senate Ways and Means.
  • Next steps: If advanced by Senate Ways and Means, the bill would move toward floor consideration and potential passage, subject to the usual legislative process in Massachusetts.

Potential impact

  • Adolescents and adults with limb loss or limb differences could gain broader, nondiscriminatory access to prosthetic and orthotic devices.
  • Insurers and MassHealth would face new requirements on coverage scope, provider access (minimum two in-state providers), and handling of out-of-network referrals.
  • Clinicians may experience standardized processes for authorization, replacement, and documentation, including situations requiring provider confirmation for recent devices.

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

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