wa-law.org > bill > 2023-24 > HB 1222 > Original Bill
For group health plans other than small group health plans issued or renewed on or after January 1, 2024, a health carrier shall include coverage for hearing instruments, including bone conduction hearing devices. This section does not include coverage for over-the-counter hearing instruments.
Coverage shall include the hearing instrument, the initial assessment, fitting, adjustment, auditory training, and ear molds as necessary to maintain optimal fit. Coverage of these services shall include services for enrollees intending to obtain or who have already obtained any hearing instrument, including over-the-counter hearing instruments.
The maximum benefit amount required by this section is $2,500 per ear with hearing loss every 36 months.
The benefit covered under this section is not subject to the covered individual's deductible unless the health plan is offered as a qualifying health plan for a health savings account. For such a qualifying health plan, the carrier shall establish the plan's cost sharing for the coverage required by this section at the minimum level necessary to preserve the enrollee's ability to claim tax exempt contributions and withdrawals from the enrollee's health savings account under internal revenue service laws and regulations.
A covered individual may choose a higher priced hearing instrument and pay the difference between the price of the hearing instrument and the benefit required under this section, without financial or contractual penalty to the covered individual or to the provider of the hearing instrument.
Coverage for a minor under 18 years of age shall be available under this section only after the minor has received medical clearance within the preceding six months from:
An otolaryngologist for an initial evaluation of hearing loss; or
A licensed physician, which indicates there has not been a substantial change in clinical status since the initial evaluation by an otolaryngologist.
For the purposes of this section:
"Hearing instrument" has the same meaning as defined in RCW 18.35.010.
"Over-the-counter hearing instrument" has the same meaning as "over-the-counter hearing aid" in 21 C.F.R. Sec. 800.30 as of December 28, 2022.
The commissioner, in consultation with the board and the health care authority, shall, by rule, select the largest small group plan in the state by enrollment as the benchmark plan for the individual and small group market for purposes of establishing the essential health benefits in Washington state.
If the essential health benefits benchmark plan for the individual and small group market does not include all of the ten essential health benefits categories, the commissioner, in consultation with the board and the health care authority, shall, by rule, supplement the benchmark plan benefits as needed.
All individual and small group health plans must cover the ten essential health benefits categories, other than a health plan offered through the federal basic health program, a grandfathered health plan, or medicaid. Such a health plan may not be offered in the state unless the commissioner finds that it is substantially equal to the benchmark plan. When making this determination, the commissioner:
Must ensure that the plan covers the ten essential health benefits categories;
May consider whether the health plan has a benefit design that would create a risk of biased selection based on health status and whether the health plan contains meaningful scope and level of benefits in each of the ten essential health benefits categories;
Notwithstanding (a) and (b) of this subsection, for benefit years beginning January 1, 2015, must establish by rule the review and approval requirements and procedures for pediatric oral services when offered in stand-alone dental plans in the nongrandfathered individual and small group markets outside of the exchange; and
Must allow health carriers to also offer pediatric oral services within the health benefit plan in the nongrandfathered individual and small group markets outside of the exchange.
Beginning December 15, 2012, and every year thereafter, the commissioner shall submit to the legislature a list of state-mandated health benefits, the enforcement of which will result in federally imposed costs to the state related to the plans sold through the exchange because the benefits are not included in the essential health benefits designated under federal law. The list must include the anticipated costs to the state of each state-mandated health benefit on the list and any statutory changes needed if funds are not appropriated to defray the state costs for the listed mandate. The commissioner may enforce a mandate on the list for the entire market only if funds are appropriated in an omnibus appropriations act specifically to pay the state portion of the identified costs.
Upon authorization by the legislature to modify the state's essential health benefits benchmark plan under 45 C.F.R. Sec. 156.111, the commissioner shall include coverage for donor human milk and hearing instruments in the updated plan.