Amendment #1 to H.4549

HOUSE . . . . . . . . No. 5626

The Commonwealth of Massachusetts

________________________________________

HOUSE OF REPRESENTATIVES, July 30, 2026.

The committee on Ways and Means, to whom was referred the Bill to improve outcomes for persons with limb loss and limb difference (House, No. 4549), reports recommending that the same ought to pass with an amendment substituting therefor the accompanying bill (House, No. 5626).

For the committee,

AARON MICHLEWITZ.

FILED ON: 7/30/2026

HOUSE . . . . . . . . . . . . . . . No. 5626

The Commonwealth of Massachusetts

_______________

In the One Hundred and Ninety-Fourth General Court
(2025-2026)

_______________

An Act to improve outcomes for persons with limb loss and limb difference.

Be it enacted by the Senate and House of Representatives in General Court assembled, and by the authority of the same, as follows:

SECTION 1. Section 17I of chapter 32A of the General Laws, as appearing in the 2024 Official Edition, is hereby amended by striking out subsections (a) and (b) and inserting in place thereof the following 2 subsections:-

(a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:

“Custom orthotic device”, a custom designed, custom fabricated, custom fitted, prefabricated or modified orthotic device.

“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.

“Orthotic services”, the design, fabrication and fitting of orthotic devices that help support weak or unstable joints or limbs, correct alignment, relieve pain or improve function. “Orthotic services” shall include, but shall not be limited to, spinal orthotic devices, scoliosis orthotic devices, knee orthotic devices, cranial remolding orthotic devices and knee-ankle-foot orthotic devices.

“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.

“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace a missing body part due to amputation, trauma or congenital limb absence or difference.

(b) The commission shall provide coverage for prosthetic devices and repairs to any active or retired employee of the commonwealth who is insured under the group insurance commission under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section.

SECTION 2. Said section 17I of said chapter 32A, as so appearing, is hereby further amended by inserting after the word “devices”, in line 29, the following words:- ; provided, that any prior authorization pursuant to this section shall be reviewed in a nondiscriminatory manner; and provided further, that the commission shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’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 2 subsections:-

(g) In addition to primary prosthetic devices 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 prosthetic devices or orthotic 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 device or orthotic device for the performance of physical activities.

(h)(1) The commission shall consider benefits pursuant to this section habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.

(2) The commission shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived disability.

(3) The commission shall not deny a prosthetic or orthotic benefit for an enrollee 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 device and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage. Such coverage may include cost-sharing on prosthetic devices 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) If the commission provides coverage for prosthetic services or orthotic services, the commission shall ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the commonwealth. If medically necessary covered orthotic devices and prosthetic devices are not available from an in-network provider, the commission shall provide processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee cost-sharing determined on an in-network basis.

(6) If coverage for prosthetic devices or custom orthotic devices is provided, payment shall be made for the replacement of a prosthetic device or custom orthotic device or for the replacement of any part of the prosthetic device or custom orthotic device, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that a replacement prosthetic device or custom orthotic device, or a replacement part of the prosthetic device or custom orthotic device, is necessary for reasons which shall include, but shall not be limited to: (i) a change in the physiological condition of the enrollee; (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 a part of the device requires repairs and the cost of such repairs would be more than 60 per cent 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 3 years old.

SECTION 4. Chapter 118E of the General Laws is hereby amended by inserting after section 10AA the following section:-

Section 10BB. (a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:

“Custom orthotic device”, a custom designed, custom fabricated, custom fitted, prefabricated or modified orthotic device.

“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.

“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace a missing body part due to amputation, trauma or congenital limb absence or difference.

(b)(1) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide coverage for prosthetic devices and orthotic devices, including the repair or replacement of prosthetic devices or orthotic devices, 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 benefits pursuant to this section habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.

(3) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived disability.

(4) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall not deny a prosthetic or orthotic benefit for an enrollee 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) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan that provides coverage for prosthetic services or orthotic services shall ensure access to medically necessary clinical care and to prosthetic and custom orthotic devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the commonwealth. If medically necessary covered orthotics and prosthetics are not available from an in-network provider, the division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan shall provide processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee cost-sharing determined on an in-network basis.

(7) If coverage for prosthetic devices or custom orthotic devices are provided by the division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan, payment shall be made for the replacement of a prosthetic device or custom orthotic device or for the replacement of any part of the prosthetic device or custom orthotic device, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that a replacement prosthetic device or custom orthotic device, or a replacement part of a prosthetic device or custom orthotic device, is necessary for reasons which shall include, but shall not be limited to: (i) a change in the physiological condition of the enrollee; (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 a part of the device requires repairs and the cost of such repairs would be more than 60 per cent 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 3 years old.

(c) In addition to primary prosthetic devices and orthotic devices for daily use, the division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization, accountable care organization or primary care clinician plan 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 device or orthotic device for the performance of physical activities.

(d) Eligible MassHealth members shall be required to provide detailed written orders, which shall include a written prescription and statement of medical necessity from the MassHealth member’s prescribing provider. The detailed written order shall include, but shall not be limited to: (i) the member’s name and address; (ii) the member’s MassHealth identification number; (iii) the specific identification of the prescribed item, including all options or additional features that will be separately billed; (iv) the member’s diagnosis; (v) a statement of medical necessity; (vi) the prescribing provider’s address and telephone number; and (vii) the date on which the prescribing provider signed the detailed written order.

SECTION 5. Section 47Z of chapter 175 of the General Laws, as appearing in the 2024 Official Edition, is hereby amended by striking out subsections (a) and (b) and inserting in place thereof the following 2 subsections:-

(a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:

“Custom orthotic device”, a custom designed, custom fabricated, custom fitted, prefabricated or modified orthotic device.

“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.

“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace a missing body part due to amputation, trauma or congenital limb absence or difference.

(b) Any blanket or general policy of insurance, except a blanket or general policy of insurance that provides supplemental coverage to Medicare or other governmental programs, described in subdivision (A), (C) or (D) of section 110, which provides hospital expense and surgical expense insurance and which is issued or subsequently renewed by agreement between the insurer and the policy holder, within or without the commonwealth, during the period this section is effective, or any policy of accident or sickness insurance, as described in section 108, which provides hospital expense and surgical expense insurance, except a policy which provides supplemental coverage to Medicare or other governmental programs, and which is delivered or issued for delivery or subsequently renewed by agreement between the insurer and the policy holder in the commonwealth, during the period that this section is effective, or any employees’ health and welfare fund, which provides hospital expense and surgical expense benefits and which is promulgated or renewed to any person or group of persons in the commonwealth, while this section is effective, shall provide coverage for prosthetic devices and repairs under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section.

SECTION 6. Said section 47Z of said chapter 175, as so appearing, is hereby further amended by inserting after the word “devices”, in line 44, the following words:- ; provided, that any prior authorization shall be reviewed in a nondiscriminatory manner; and provided further, that no such policy shall deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’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) In addition to primary prosthetic devices and orthotic devices for daily use, any such policy 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 prosthetic devices or orthotic 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 device or orthotic device for the performance of physical activities.

(2) Any such policy shall consider benefits pursuant to this section habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.

(3) Any such policy shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived disability.

(4) Any such policy shall not deny a prosthetic or orthotic benefit for an enrollee 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 device and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage. Any such policy may include cost-sharing on prosthetic devices 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 services or orthotic services shall ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the commonwealth. If medically necessary covered orthotic devices and prosthetic devices are not available from an in-network provider, any such policy shall provide processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee cost-sharing determined on an in-network basis.

(7) If coverage for prosthetic devices or custom orthotic devices is provided, payment shall be made for the replacement of a prosthetic device or custom orthotic device or for the replacement of any part of the prosthetic device or custom orthotic device, without regard to continuous use or useful lifetime restrictions, if an ordering health care provider determines that a replacement prosthetic device or custom orthotic device, or a replacement part of the prosthetic device or custom orthotic device, is necessary for reasons which shall include, but shall not be limited to: (i) a change in the physiological condition of the enrollee; (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 a part of the device requires repairs and the cost of such repairs would be more than 60 per cent 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 3 years old.

SECTION 8. Section 8AA of chapter 176A of the General Laws, as so appearing, is hereby amended by striking out subsections (a) and (b) and inserting in place thereof the following 2 subsections:-

(a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:

“Custom orthotic device”, a custom designed, custom fabricated, custom fitted, prefabricated or modified orthotic device.

“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.

“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace a missing body part due to amputation, trauma or congenital limb absence or difference.

(b) A contract between a subscriber and the corporation under an individual or group hospital service plan that provides hospital expense and surgical expense insurance, except contracts providing supplemental coverage to Medicare or other governmental programs, delivered, issued or renewed by agreement between the insurer and the policyholder, within or without the commonwealth, shall provide benefits to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth for coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the contract, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone benefit, coverage shall be consistent with the terms and conditions as described in this section.

SECTION 9. Said section 8AA of said chapter 176A, as so appearing, is hereby further amended by inserting after the word “devices”, in line 40, the following words:- ; provided, that any prior authorization shall be reviewed in a nondiscriminatory manner; and provided further, that no such contract shall deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’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)(1) In addition to primary prosthetic devices and orthotic devices for daily use, any such contract 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 prosthetic devices or orthotic 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 device or orthotic device for the performance of physical activities.

(2) Any such contract shall consider benefits pursuant to this section habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.

(3) Any such contract shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived disability.

(4) Any such contract shall not deny a prosthetic or orthotic benefit for an enrollee 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 device and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage. Any such contract may include cost-sharing on prosthetic devices 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 services or orthotic services shall ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the commonwealth. If medically necessary covered orthotic devices and prosthetic devices are not available from an in-network provider, any such contract shall provide processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee cost-sharing determined on an in-network basis.

SECTION 11. Section 4AA of chapter 176B of the General Laws, as so appearing, is hereby amended by striking out subsections (a) and (b) and inserting in place thereof the following 2 subsections:-

(a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:

“Custom orthotic device”, a custom designed, custom fabricated, custom fitted, prefabricated or modified orthotic device.

“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.

“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace a missing body part due to amputation, trauma or congenital limb absence or difference.

(b) Any subscription certificate under an individual or group medical service agreement, except certificates that provide supplemental coverage to Medicare or other governmental programs, that is delivered, issued or renewed within the commonwealth, shall provide, as benefits to all individual subscribers or members within the commonwealth and to all group members having a principal place of employment within the commonwealth, coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the policy, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be consistent with the terms and conditions as described in this section.

SECTION 12. Said section 4AA of said chapter 176B, as so appearing, is hereby further amended by amended by inserting after the word “devices”, in line 38, the following words:- ; provided, that any prior authorization shall be reviewed in a nondiscriminatory manner; and provided further, that no such policy shall deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’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) In addition to primary prosthetic devices and orthotic devices for daily use, any such certificate 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 prosthetic devices or orthotic 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 device or orthotic device for the performance of physical activities.

(2) Any such certificate shall consider benefits pursuant to this section habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.

(3) Any such certificate shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived disability.

(4) Any such certificate shall not deny a prosthetic or orthotic benefit for an enrollee 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 device and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage. Any such certificate may include cost-sharing on prosthetic devices 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 services or orthotic services shall ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the commonwealth. If medically necessary covered orthotic devices and prosthetic devices are not available from an in-network provider, any such certificate shall provide processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee cost-sharing determined on an in-network basis.

SECTION 14. Section 4S of chapter 176G of the General Laws, as so appearing, is hereby amended by striking out subsections (a) and (b) and inserting in place thereof the following 2 subsections:-

(a) As used in this section, the following words shall, unless the context clearly requires otherwise, have the following meanings:

“Custom orthotic device”, a custom designed, custom fabricated, custom fitted, prefabricated or modified orthotic device.

“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.

“Prosthetic services”, the design, fabrication and fitting of prosthetic devices that replace a missing body part due to amputation, trauma or congenital limb absence or difference.

(b) Individual and group health maintenance contracts shall provide coverage for prosthetic devices and repairs. If prosthetic devices are covered as a durable medical equipment benefit, coverage shall be provided under the same terms and conditions that apply to other durable medical equipment covered under the contracts, except as otherwise provided in this section. If prosthetic devices are covered as a stand-alone prosthetic benefit, coverage shall be consistent with the terms and conditions as described in this section.

SECTION 15. Said section 4S of said chapter 176G, as so appearing, is hereby further amended by inserting after the word “devices”, in line 33, the following words:- ; provided, that any prior authorization shall be reviewed in a nondiscriminatory manner; and provided further, that no such policy shall deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’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) In addition to primary prosthetic devices and orthotic devices for daily use, a health maintenance contract 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 prosthetic devices or orthotic 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 device or orthotic device for the performance of physical activities.

(2) A health maintenance contract shall consider benefits pursuant to this section habilitative or rehabilitative for purposes of any state or federal requirement for coverage of essential health benefits.

(3) A health maintenance contract shall render utilization determinations in a nondiscriminatory manner and shall not deny coverage for habilitative or rehabilitative benefits, including prosthetic devices or orthotic devices, solely on the basis of an enrollee’s actual or perceived disability.

(4) A health maintenance contract shall not deny a prosthetic or orthotic benefit for an enrollee 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 device and custom orthotic device coverage shall not be subject to separate financial requirements that are applicable only with respect to that coverage. A health maintenance contract may include cost-sharing on prosthetic devices 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 services or orthotic services shall ensure access to medically necessary clinical care and to prosthetic devices and custom orthotic devices and technology from not less than 2 distinct prosthetic and custom orthotic providers in the managed care plan’s provider network located in the commonwealth. If medically necessary covered orthotic devices and prosthetic devices are not available from an in-network provider, a health maintenance contract shall provide processes to refer an enrollee to an out-of-network provider and shall fully reimburse the out-of-network provider at a mutually agreed upon rate less enrollee cost-sharing determined on an in-network basis.