TITLE 33 INSURANCE

Section 24. Insurance Generally, 33-24-1 through 33-24-98.

ARTICLE 1 GENERAL PROVISIONS

33-24-59.21. Health plans to provide coverage for hearing aids for certain individuals; frequency of replacement; coverage of services and supplies; options for higher priced devices.

1. This Code section shall be known and may be cited as the "Hearing Aid Coverage for Children Act."
2. The General Assembly finds and declares that:
   1. The language development of children with partial or total hearing loss may be impaired due to the hearing loss. Children learn the concept of spoken language through auditory stimuli, and the language skills of children who have hearing loss improve when they are provided with hearing aids and access to visual language upon the discovery of hearing loss; and
   2. Providing hearing aids to children with hearing loss will reduce the costs borne by this state, including special education, alternative treatments that would otherwise be necessary if a hearing aid were not provided, and other costs associated with such hearing loss.
3. As used in this Code section, the term:
   1. "Health benefit policy" means any individual or group plan, policy, or contract for health care services issued, delivered, issued for delivery, or renewed in this state which provides major medical benefits, including those contracts executed by the State of Georgia on behalf of indigents and on behalf of state employees under Article 1 of Chapter 18 of Title 45, by a health care corporation, health maintenance organization, preferred provider organization, accident and sickness insurer, fraternal benefit society, hospital service corporation, medical service corporation, or any similar entity and any self-insured health care plan not subject to the exclusive jurisdiction of the Employee Retirement Income Security Act of 1974, 29 U.S.C. Section 1001, et seq.
   2. "Hearing aid" means any nonexperimental and wearable instrument or device offered to aid or compensate for impaired human hearing that is worn in or on the body. The term "hearing aid" includes any parts, ear molds, repair parts, and replacement parts of such instrument or device, including, but not limited to, nonimplanted bone anchored hearing aids, nonimplanted bone conduction hearing aids, and frequency modulation systems. Personal sound amplification products shall not qualify as hearing aids.
4. Every health benefit policy that is delivered, issued, executed, or renewed in this state or approved for issuance or renewal in this state by the Commissioner on or after January 1, 2018, shall provide coverage for the billed charges of one hearing aid per hearing impaired ear not to exceed $3,000.00 per hearing aid for covered individuals 18 years of age or under. Such coverage shall provide the replacement for one hearing aid per hearing impaired ear every 48 months for covered individuals. The parent or guardian of such individual is responsible for billed charges in excess of such benefits. This subsection shall not prohibit an entity subject to this Code section from providing coverage that is greater or more favorable to an insured or enrolled individual than the coverage required under this Code section.
5. In the event that a hearing aid or aids cannot adequately meet the needs of the covered individual and the hearing aid or aids cannot be adequately repaired or adjusted, the hearing aid or aids shall be replaced. Coverage for the replacement shall be offered within two months from the date it is determined that the hearing aid or aids cannot be repaired or adjusted.
6. The coverage provided by this Code section shall include the following:
   1. Medically necessary services and supplies, including the initial hearing aid evaluation, fitting, dispensing, programming, servicing, repairs, follow-up maintenance, adjustments, ear molds, ear mold impressions, auditory training, and probe microphone measurements to ensure appropriate gain and output, as well as verifying benefit from the system selected according to accepted professional standards. Such services shall be covered on a continuous basis, as needed, during each 48 month coverage period not to exceed $3,000.00 per hearing impaired ear or for the duration of the hearing aid warranty, whichever time period is longer;
   2. An option for the covered individual to choose a higher priced hearing aid or aids and to pay the difference between the price of the hearing aid or aids and the benefit amount as referenced in subsection (d) of this Code section, without financial or contractual penalty to the insured or to the provider of the hearing aid; and
   3. An option for the covered individual to purchase his or her hearing aid or aids through any licensed audiologist or licensed hearing aid dealer or dispenser in this state.
7. A health benefit policy shall not deny or refuse coverage of, refuse to contract with, or refuse to renew or reissue or otherwise terminate or restrict coverage of a covered individual solely because he or she is or has been previously diagnosed with hearing loss.
8. The benefits covered under this Code section shall be subject to the same annual deductible, coinsurance or copayment, or utilization review applicable to other similar covered benefits under the health benefit policy.
9. An insurer, corporation, health maintenance organization, or governmental entity providing coverage for a hearing aid or aids pursuant to this Code section is exempt from providing coverage for children's hearing aids required under this Code section and not covered by the insurer, corporation, health maintenance organization, or governmental entity providing coverage for such treatment pursuant to this Code section as of January 1, 2019, if:
   1. An actuary affiliated with the insurer, corporation, health maintenance organization, or governmental entity who is a member of the American Academy of Actuaries and who meets the American Academy of Actuaries' professional qualification standards for rendering an actuarial opinion related to health insurance rate making certifies in writing to the Commissioner that:
      1. Based on an analysis to be completed no more frequently than one time per year by each insurer, corporation, health maintenance organization, or governmental entity for the most recent experience period of at least one year's duration, the costs associated with coverage of children's hearing aids required under this Code section, and not covered as of January 1, 2019, exceeded 1 percent of the premiums charged over the experience period by the insurer, corporation, or health maintenance organization; and
      2. Such costs solely would lead to an insurance in average premiums charged of more than 1 percent for all insurance policies, subscription contracts, or health care plans commencing on inception or the next renewal date, based on the premium rating methodology and practices the insurer, corporation, health maintenance organization, or governmental entity employs; and
   2. The Commissioner approves the certification of the actuary.
10. Beginning January 1, 2018, to the extent that this Code section requires benefits that exceed the essential health benefits required under Section 1302(b) of the federal Patient Protection and Affordable Care Act, P. L. 111-148, the specific benefits that exceed the required essential health benefits shall not be required of a qualified health plan as defined in such act when the qualified health plan is offered in this state through the exchange. Nothing in this subsection shall nullify the application of this Code section to plans offered outside the state's exchange.
11. This Code section shall not apply to any accident and sickness contract, policy, or benefit plan offered by any employer with ten or fewer employees.

(Code 1981, §33-24-59.21, enacted by Ga. L. 2017, p. 361, § 1/SB 206.)