Service Limitations

The MassHealth agency pays for all medically necessary orthotics subject to the service limitations set forth in 130 CMR 442.000; the Orthotics Manual, Subchapter 6 of; and the MassHealth Orthotics and Prosthetics Payment and Coverage Guidelines Tool, subject to the Early and Periodic Screening, Diagnosis, and Treatment provisions set forth in 130 CMR 450.144(A): EPSDT Services: Diagnosis and Treatment. (A) Nonstandard Size (Width or Length). A provider may bill an additional charge for a nonstandard size for off-the-shelf, medical-grade orthopedic shoes once per pair. (B) Split-size Change. A provider may bill a split-size charge for off-the-shelf, medical-grade orthopedic shoes once per pair. (C) Custom-molded Shoe Inserts. When a manufacturer offers a custom-molded shoe that includes the insert, the provider of orthotics must not bill separately for the initial insert. (D) Closure Modification. When a manufacturer offers an off-the-shelf shoe that comes standard with either lace or velcro enclosures, the provider of orthotics must choose the appropriate shoe to meet the member’s needs, and not bill separately for closure modification.