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H 4549

Sine Die Addition

2025-2026 Regular Session Introduced by Jordan Pace

Expands insurance coverage for prosthetic/orthotic devices and repairs, ensures access via in-state providers, and prohibits discrimination based on disability to improve functiona

Roll call Yeas-87 Nays-22
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Bill Summary · H 4549

Summary — H.4549 (House No. 4549)

Title: An Act to improve outcomes for persons with limb loss and limb difference
Classification: Concurrent resolution / Act language included
Introduced: 05/08/2025; Committee report: 09/29/2025
Key procedural status: Roll call Yeas 87 — Nays 22 (05/08/2025). Reported favorably by the Committee on Financial Services (9/29/2025) and referred to Health Care Financing. Committee recommended the bill “ought to pass.”

Purpose

H.4549 would expand and clarify insurance coverage requirements for prosthetic and orthotic devices across state group plans and MassHealth to improve functional outcomes for people with limb loss or limb difference. It also contains (as filed) a concurrent resolution provision permitting certain bills related to “protection of human rights of preborn people” to be introduced and considered after May 8, 2025 (a procedural sine die addition).

Key substantive provisions (prosthetics / orthotics)

  • Definitions: Explicit definitions of “Orthosis” and “Prosthetic device” (including activity-specific prostheses).
  • Coverage scope:
    • Requires coverage for primary prosthetic and orthotic devices for daily use and devices specifically designed, custom-built, or fitted for physical activities (e.g., devices for ambulation, running, biking, swimming, showering/bathing, and upper-limb function).
    • Coverage must include repair and replacement of such devices.
  • Classification and nondiscrimination:
    • Directs the Division (and insurers) to treat these benefits as habilitative or rehabilitative for purposes of essential health benefits.
    • Prohibits denial of habilitative/rehabilitative benefits (including prosthetics/orthotics) based solely on an insured’s actual or perceived disability.
    • Prohibits denying benefits for an individual with limb loss/absence that would be covered for a non‑disabled person seeking comparable medical/surgical intervention.
  • Cost-sharing and financial requirements:
    • Prosthetic/custom orthotic coverage may not be subject to special separate financial requirements applicable only to that coverage.
    • Any cost-sharing for these devices may be imposed, but must not be more restrictive than the plan’s cost-sharing for inpatient physician and surgical services.
  • Network and access:
    • Managed care plans must ensure access to medically necessary prosthetic/orthotic care from at least two distinct in-state prosthetic/orthotic providers in-network.
    • If in-network providers are not available, plans must allow referrals to out-of-network providers and “fully reimburse” them at a mutually agreed rate, with member cost-sharing determined on an in-network basis.
  • Replacement and repair rules:
    • Payment for replacement of devices or parts is required without reliance on continuous-use or “useful lifetime” restrictions when medically necessary (examples: change in patient physiology, irreparable device damage, or repair cost exceeding 60% of replacement cost).
    • If the replaced device/part is less than three years old, confirmation from the prescribing provider may be required.
  • MassHealth:
    • MassHealth must cover prosthetic and orthotic devices (including repair/replacement) under the same terms and conditions that apply to other durable medical equipment benefits and considers them habilitative/rehabilitative.

Who is affected

  • Primary beneficiaries: People with limb loss or limb difference (state employees covered under chapter 32A plans, MassHealth members, and privately insured individuals in plans subject to these standards).
  • Insurers and managed care plans: Required to revise utilization, network, cost-sharing and reimbursement practices to comply.
  • Prosthetic and orthotic providers: Network access provisions and reimbursement rules affect provider contracting and out‑of‑network referrals.
  • State agencies: Group Insurance Commission / Division and MassHealth must implement regulatory/coverage changes.

Procedural / timeline notes

  • Introduced and placed in Committee on Rules: 05/08/2025 (roll call final passage of the concurrent resolution language occurred 05/08/2025: Yeas 87 — Nays 22).
  • New draft and committee report from Financial Services filed 09/29/2025; referred to Health Care Financing for further consideration.
  • Committee on Financial Services recommended passage (report filed 09/29/2025).

Potential impact and considerations

  • Would expand access to activity-specific prosthetic and custom orthotic devices and limit insurer practices that can deny such benefits to people with disabilities.
  • May increase coverage obligations and costs for insurers and for MassHealth/durable medical equipment budgets, while improving functional outcomes and participation in daily/physical activities for beneficiaries.
  • Implementation will require plan policy changes, network development, and possible regulatory guidance to define “medically necessary,” provider qualifications, reimbursement methods, and enforcement of nondiscrimination provisions.

(Prepared from the bill text and legislative action history filed with House No. 4549.)

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

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