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.