Frequently Asked Questions Regarding New Law

  • What does the law provide? Chapter 233 provides insurance coverage for hearing aids for children 21 years old and younger up to $2,000 per hearing aid for each hearing impaired ear in each 36-month period.
  • When is the effective date of the law?The law applies to all health plans that are delivered, issued or renewed on or after January 1, 2013. This means that coverage becomes effective as policies are renewed throughout 2013. Following this year, coverage will remain continuous under health insurance policies. Before you begin the process of purchasing hearing aids, check with your health insurance carrier to verify the specific date on which your coverage will be effective. Example: Your health insurance plan renews on July 1st. Coverage becomes effective under your policy on July 1st. This means that you may not purchase hearing aids for your child or seek coverage for related services and supplies under this law until July 1st.
  • What does the $2,000 cap include?The $2,000 cap includes coverage for each hearing aid device. An insured may select a higher-priced hearing aid and pay the difference in cost above the $2,000 limit for the device. Plans must also cover all services related to a covered hearing aid device, including the initial hearing aid evaluation, fitting and adjustments and supplies, including ear molds. These amounts are not included in the $2,000 coverage limit that applies to the hearing aid device, but are covered separately and outright under your plan.
  • Are batteries covered? Yes. Coverage under this law includes related services, including the initial hearing aid evaluation, hearing aid fittings and adjustments and supplies. Batteries are covered under the "supplies" section of the law. A billing code already exists for hearing aid batteries- your dispensing audiologist should have this.
  • How about ear molds? Ear molds are covered under this law.
  • Who is covered? Children 21 years of age or younger who are covered under fully-insured plans.
  • Who is not covered?Children who are covered under self-insured plans are not covered by this law. A self-insured (or self-funded) plan is one in which the employer assumes the financial risk for providing health care benefits to its employees, even if an insurance company is used to process the claims. Self-insured plans are governed by federal ERISA laws and are not subject to state mandates or regulation by the state Division of Insurance. This means that self-insured employers will not be required to provide hearing aid coverage under Chapter 233.
  • How do I know if my plan is fully-insured?You may find out if your plan is fully-insured by contacting your insurance carrier or your Human Resources department at your place of employment.
  • What do I do if I find out that my plan is self-insured? You may advocate for your child! Contact your employer to explain why they should add this coverage to their insurance plan. Often employers will follow state mandates by adding similar coverage. One reason employers decide to self-insure is so that they may customize a plan to meet the specific needs of their workforce. If an employee is in need of specific coverage, an employer may consider adding the benefit. The final decision rests with your employer.
  • What if my plan has a high deductible? Chapter 233 allows carriers to apply deductibles, coinsurance, co-payments or out-of-pocket limits to hearing aid devices, supplies and services related to hearing aids, but they may not be greater than any applied to other benefits covered in the health plan. If you have a high deductible that would effectively cancel out the benefit afforded by this law, you may wish to shop around for another health insurance carrier. If this is not possible, consider appealing to your health insurance carrier to provide the coverage. Every health insurance carrier has a dispute resolution process and must consider your appeal.
  • Must I live in Massachusetts to be covered under this law?Not necessarily. If you work for an employer that is located in Massachusetts but reside outside of Massachusetts, you are most likely eligible for benefits under Chapter 233. To be sure, check with your Human Resources department.
  • What if I live in Massachusetts but work for an out-of-state employer? If your employer is located outside Massachusetts, you are most likely ineligible for benefits under Chapter 233 because your employer would be subject to insurance mandates and oversight by the state in which it is located. To be sure, check with your Human Resources department.
  • What do I do once I find out that my child is eligible to purchase hearing aids under this law? Once you determine that your child is covered by a fully-funded plan and are certain of your renewal date, you will need a written statement from your child’s treating physician that the hearing aids are necessary. Either your child’s pediatrician or ENT may provide this written statement. Then, your child’s audiologist will recommend a hearing aid that best fits your child.
  • Can my child be denied hearing aids depending on how the hearing loss occurred? No. Chapter 233 provides that a child must be afforded coverage for hearing aids if a treating physician or ENT issues a written statement that the hearing aids are necessary regardless of how the hearing loss occurred (e.g., at birth, late onset, accident, illness).
  • Is this law based on income levels? No. Any child 21 years of age or younger who resides in Massachusetts, is covered by a fully-insured health plan and meets the other requirements listed in the law is eligible to receive the benefit.
  • Is there anything that I need to know about talking to my health insurance company? Always get the full name, phone number and extension of the insurance representative with whom you speak in the event that you or someone else will need to follow up on the conversation. Take notes during your discussions and keep the notes in a file or notebook so that you may refer to them again, if necessary.
  • What if I am eligible for coverage under this law but my insurance company denies or delays coverage? If you are denied coverage or coverage is unduly delayed by your insurance company, you may file an appeal or grievance with your insurance company or you may contact the Bureau of Managed Care at the Division of Insurance in Boston to file a complaint by phone, fax or e-mail. You may also contact the Office of Patient Protection at the Department of Public Health in Boston.
  • Additional resources:Bureau of Managed Care Division of Insurance Office of Consumer Affairs and Business Regulations 1000 Washington Street, Suite 810 Boston, MA 02118 Tel: (617) 521-7372 Fax: (617) 521-7773 www.mass.gov/doi/ E-mail: bmc.mailbox@state.ma.us
  • Universal Newborn Hearing Screening Program Department of Public Health 250 Washington Street, 5th Floor Boston, MA 02108 Tel: 1-800-882-1435

Thursday, January 30, 2014

A Loophole or the Law?


IS YOUR EMPLOYER SELF-INSURED?

On January 1, 2014, the new hearing aid law for children in MA turned 1 year old. It is still too soon to understand how many children benefited since the law rolled out during 2013 as health insurance enrollment dates came due. Now the law is fully operational and part of your insurance coverage under the state mandate if your employer is commercially insured. What does that mean? Why are some children still unable to benefit from the law? Is there a loophole in coverage?

SELF-INSURED V. COMMERCIALLY INSURED PLANS

An employer can provide health insurance to its workers in a few ways. Some employers elect to pay a premium to health insurance companies for health benefits for its employees. Employees may share in that premium. These are commercially insured plans and they are regulated at the STATE level, which means that they must follow STATE laws. The new hearing aid mandate is one of these STATE laws that applies to all commercially funded insurance plans in the Commonwealth. These insurers must also follow federal laws, like the Affordable Care Act. The relationship goes something like this:

EMPLOYER - HEALTH INSURANCE COMPANY - EMPLOYEE

Other employers may chose to self-fund health insurance. This means that the employer pays for all of its employees' health care costs directly instead of paying a health insurance company to handle health insurance. Self-insured plans are governed by FEDERAL laws, like ERISA (the Employee Retirement Income Security Act) and are not subject to state laws, including state insurance mandates.  Here is what this relationship looks like with respect to health care coverage:

EMPLOYER - EMPLOYEE

This means that self-insured employers in MA are not legally (legislatively) required to provide hearing aid coverage under the new hearing aid law. They don't have to because they are governed by FEDERAL laws. This is just the way the law and our legislative system work.

THERE IS NO LOOPHOLE, IT'S JUST THE LAW

What if your employer self-funds your health insurance and your child needs hearing aids?
  • Ask your employer to add the benefit! Talk to your Human Resources Department and explain why your employer should add insurance coverage for hearing aids for children to its insurance benefits package. Often employers will follow state mandates by adding similar coverage. One reason employers decide to self-insure is so they may customize a plan to meet the specific needs of their workforce. If an employee needs specific coverage, an employer may consider adding the benefit. The final decision, however, rests with your employer.
  • Some employers prefer to provide health insurance benefits that mirror coverage mandated by the state. Perhaps your employer will add the benefit to its insurance plan because other children in the Commonwealth are receiving the benefit. Your employer may feel that health mandates signal a gap in health care coverage that legislators and health care officials felt strongly enough to address. Your employer may also realize that providing coverage for hearing aids reduces other health insurance costs along the way, like coverage for speech and language therapy services, medical costs associated with untreated pediatric hearing loss or costs associated with the social and emotional well-being of a child. Your employer doesn't feel this way? Then educate your employer!

EDUCATE YOUR EMPLOYER AND ADVOCATE FOR YOUR CHILD!

  • If you are thinking of getting involved at the legislative level, go to Washington D.C.! Lobby to have full insurance coverage for pediatric hearing aids added to the Affordable Care Act (ACA). This would provide coverage for ALL children in every state of the United States. In fact, early versions of the ACA included coverage for pediatric hearing aids, but this coverage dropped out in later versions. The FEDERAL law that controls self-funded plans (and commercially insured plans) needs to be changed, not the STATE hearing aid law for children.
  • Talk to your U.S. Senator. Schedule a meeting to discuss this issue. Ask your Senator to take this issue up in Congress.

  • Folks at the Universal Newborn Hearing Screening Program, Department of Public Health, 250 Washington Street, 5th Floor, Boston MA 02108 Tel: 1-800-882-1435 do a great job of explaining this conundrum. Don't believe us? Give them a call!
 
This information is not intended as legal advice. It is purely informational and intended to
educate consumers about the new hearing aid law in MA.