MedicaidCoverageHigh impact
Updated Orthoses and Protheses Coverage Expansion under the So Every Body Can Move Act, Effective January 1, 2025
Maryland Medicaid·MD · Orthopedics, Physical Therapy, PM&R (Physical Medicine & Rehab) +1 more·DME/DMS
Effective date
Jan 1, 2025
We identified it
Jun 20, 2026
Summary
Maryland Medicaid expands prosthetic device coverage effective January 1, 2025, to include two annual benefits: one for home/school/employment use and one for sports/physical activities. Custom prosthetics are now covered for limb loss restoration. Orthotic coverage remains in home/school/employment settings. Prior authorization thresholds are $1,000+ for prostheses (FFS) and $500+ for orthoses.
Action Required
By January 1, 2025: Billing team must implement the following changes: (1) Update billing system to recognize TWO separate annual prosthetic benefits per Medicaid member — one for ADL/work use and one for sports/activity use; (2) Configure prior authorization requirements: prostheses ≥$1,000 require prepayment auth for FFS members, MCO members require auth per plan policy; (3) Configure prior authorization requirements: orthoses ≥$500 require prepayment auth for FFS members, MCO members per plan discretion; (4) Update claim submission logic to allow replacement prostheses <3 years old if medically justified (physiological change, irreparable damage, or repair cost >60% of replacement); (5) Train billing and authorization staff on expanded prosthetic coverage codes (L-series codes per Maryland FFS fee schedule); (6) Contact all MCOs to obtain their specific prior authorization and reimbursement policies for prosthetics and orthoses; (7) Update patient eligibility verification to flag Medicaid members for these benefits. Failure to implement proper prior authorization will result in claim denials. Contact Karen Gaines (karen.gaines@maryland.gov) for clarification.