Ally’s Act

Subjects: Health


<html><body><pre>[Congressional Bills 118th Congress]
[From the U.S. Government Publishing Office]
[S. 1135 Introduced in Senate (IS)]

&lt;DOC&gt;






118th CONGRESS
  1st Session
                                S. 1135

  To amend title XXVII of the Public Health Service Act, the Employee 
 Retirement Income Security Act of 1974, the Internal Revenue Code of 
  1986, and the Patient Protection and Affordable Care Act to require 
   coverage of hearing devices and systems in certain private health 
                insurance plans, and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             March 30, 2023

Mrs. Capito (for herself, Ms. Warren, and Mr. Hickenlooper) introduced 
the following bill; which was read twice and referred to the Committee 
               on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
  To amend title XXVII of the Public Health Service Act, the Employee 
 Retirement Income Security Act of 1974, the Internal Revenue Code of 
  1986, and the Patient Protection and Affordable Care Act to require 
   coverage of hearing devices and systems in certain private health 
                insurance plans, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as ``Ally's Act''.

SEC. 2. COVERAGE OF HEARING DEVICES AND SYSTEMS IN CERTAIN PRIVATE 
              HEALTH INSURANCE PLANS.

    (a) PHSA.--Part D of the Public Health Service Act (42 U.S.C. 
300gg-111 et seq.) is amended by adding at the end the following new 
section:

``SEC. 2799A-11. COVERAGE OF HEARING DEVICES AND SYSTEMS.

    ``(a) In General.--A group health plan and a health insurance 
issuer offering group or individual health insurance coverage shall at 
a minimum provide coverage for the following items and services 
furnished to a qualifying individual:
            ``(1) Auditory implant devices (including auditory 
        osseointegrated (bone conduction) implants and cochlear 
        implants) and external sound processors.
            ``(2) The maintenance of auditory implant devices and 
        external sound processors described in paragraph (1).
            ``(3) Every 5 years, the upgrade (or replacement if an 
        upgrade is not available) of auditory implant devices and 
        external sound processors described in paragraph (1).
            ``(4) Adhesive adapters and softband headbands.
            ``(5) The repair of auditory implant devices and external 
        sound processors described in paragraph (1).
            ``(6) A comprehensive hearing assessment.
            ``(7) A preoperative medical assessment.
            ``(8) Surgery relating to the furnishing of such devices 
        and processors (as determined necessary by a physician or 
        qualified audiologist (as such terms are defined for purposes 
        of subsection (d)) treating such individual).
            ``(9) Postoperative medical visits for purposes of ensuring 
        appropriate recovery from such surgery.
            ``(10) Postoperative audiological visits for activation and 
        fitting of such devices and processors.
            ``(11) Aural rehabilitation and treatment services (as so 
        determined necessary).
    ``(b) Coverage Requirements.--In the case of an item or service 
described in subsection (a) furnished to a qualifying individual under 
a group health plan or group or individual health insurance coverage, 
such plan or coverage shall ensure that--
            ``(1) the financial requirements (as defined in section 
        2726(a)(3)) applicable to such item or service are no more 
        restrictive than the predominant financial requirements applied 
        to substantially all medical and surgical benefits covered by 
        the plan or coverage (as applicable), and that there are no 
        separate cost sharing requirements that are applicable only 
        with respect to such item or service; and
            ``(2) the treatment limitations (as defined in such 
        section) applicable to such item or service are no more 
        restrictive than the predominant treatment limitations applied 
        to substantially all medical and surgical benefits covered by 
        the plan or coverage (as applicable), and that there are no 
        separate treatment limitations that are applicable only with 
        respect to such item or service.
    ``(c) Prohibition on Review of Medical Necessity.--A group health 
plan and a health insurance issuer offering group or individual health 
insurance coverage may not deny or otherwise limit coverage of any item 
or service described in subsection (a) furnished to a qualifying 
individual on the basis of a review of the medical necessity of such 
item or service by such plan or issuer.
    ``(d) Qualifying Individual Defined.--For purposes of this section, 
the term `qualifying individual' means an individual that a physician 
(as defined in section 1861(r) of the Social Security Act) or qualified 
audiologist (as defined in section 1861(ll)(4)(B) of such Act) 
determines meets an indication (including unilateral or bilateral 
hearing loss) for an auditory implant device and external sound 
processor described in subsection (a)(1).''.
    (b) ERISA.--
            (1) In general.--Subpart B of part 7 of subtitle B of title 
        I of the Employee Retirement Income Security Act of 1974 (29 
        U.S.C. 1185 et seq.) by adding at the end the following new 
        section:

``SEC. 726. COVERAGE OF HEARING DEVICES AND SYSTEMS.

    ``(a) In General.--A group health plan and a health insurance 
issuer offering group health insurance coverage shall at a minimum 
provide coverage for the following items and services furnished to a 
qualifying individual:
            ``(1) Auditory implant devices (including auditory 
        osseointegrated (bone conduction) implants and cochlear 
        implants) and external sound processors.
            ``(2) The maintenance of auditory implant devices and 
        external sound processors described in paragraph (1).
            ``(3) Every 5 years, the upgrade (or replacement if an 
        upgrade is not available) of auditory implant devices and 
        external sound processors described in paragraph (1).
            ``(4) Adhesive adapters and softband headbands.
            ``(5) The repair of auditory implant devices and external 
        sound processors described in paragraph (1).
            ``(6) A comprehensive hearing assessment.
            ``(7) A preoperative medical assessment.
            ``(8) Surgery relating to the furnishing of such devices 
        and processors (as determined necessary by a physician or 
        qualified audiologist (as such terms are defined for purposes 
        of subsection (d)) treating such individual).
            ``(9) Postoperative medical visits for purposes of ensuring 
        appropriate recovery from such surgery.
            ``(10) Postoperative audiological visits for activation and 
        fitting of such devices and processors.
            ``(11) Aural rehabilitation and treatment services (as so 
        determined necessary).
    ``(b) Coverage Requirements.--In the case of an item or service 
described in subsection (a) furnished to a qualifying individual under 
a group health plan or group health insurance coverage, such plan or 
coverage shall ensure that--
            ``(1) the financial requirements (as defined in section 
        2726(a)(3) of the Public Health Service Act (42 U.S.C. 300gg-
        26(a)(3))) applicable to such item or service are no more 
        restrictive than the predominant financial requirements applied 
        to substantially all medical and surgical benefits covered by 
        the plan or coverage (as applicable), and that there are no 
        separate cost sharing requirements that are applicable only 
        with respect to such item or service; and
            ``(2) the treatment limitations (as defined in such 
        section) applicable to such item or service are no more 
        restrictive than the predominant treatment limitations applied 
        to substantially all medical and surgical benefits covered by 
        the plan or coverage (as applicable), and that there are no 
        separate treatment limitations that are applicable only with 
        respect to such item or service.
    ``(c) Prohibition on Review of Medical Necessity.--A group health 
plan and a health insurance issuer offering group health insurance 
coverage may not deny or otherwise limit coverage of any item or 
service described in subsection (a) furnished to a qualifying 
individual on the basis of a review of the medical necessity of such 
item or service by such plan or issuer.
    ``(d) Qualifying Individual Defined.--For purposes of this section, 
the term `qualifying individual' means an individual that a physician 
(as defined in section 1861(r) of the Social Security Act (42 U.S.C. 
1395x(r))) or qualified audiologist (as defined in section 
1861(ll)(4)(B) of such Act (42 U.S.C. 1395x(ll)(4)(B))) determines 
meets an indication (including unilateral or bilateral hearing loss) 
for an auditory implant device and external sound processor described 
in subsection (a)(1).''.
            (2) Clerical amendment.--The table of contents in section 1 
        of the Employee Retirement Income Security Act of 1974 (29 
        U.S.C. 1001 et seq.) is amended by inserting after the item 
        relating to section 725 the following new item:

``Sec. 726. Coverage of hearing devices and systems.''.
    (c) IRC.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986 is amended by adding at the end 
        the following new section:

``SEC. 9826. COVERAGE OF HEARING DEVICES AND SYSTEMS.

    ``(a) In General.--A group health plan shall at a minimum provide 
coverage for the following items and services furnished to a qualifying 
individual:
            ``(1) Auditory implant devices (including auditory 
        osseointegrated (bone conduction) implants and cochlear 
        implants) and external sound processors.
            ``(2) The maintenance of auditory implant devices and 
        external sound processors described in paragraph (1).
            ``(3) Every 5 years, the upgrade (or replacement if an 
        upgrade is not available) of auditory implant devices and 
        external sound processors described in paragraph (1).
            ``(4) Adhesive adapters and softband headbands.
            ``(5) The repair of auditory implant devices and external 
        sound processors described in paragraph (1).
            ``(6) A comprehensive hearing assessment.
            ``(7) A preoperative medical assessment.
            ``(8) Surgery relating to the furnishing of such devices 
        and processors (as determined necessary by a physician or 
        qualified audiologist (as such terms are defined for purposes 
        of subsection (d)) treating such individual).
            ``(9) Postoperative medical visits for purposes of ensuring 
        appropriate recovery from such surgery.
            ``(10) Postoperative audiological visits for activation and 
        fitting of such devices and processors.
            ``(11) Aural rehabilitation and treatment services (as so 
        determined necessary).
    ``(b) Coverage Requirements.--In the case of an item or service 
described in subsection (a) furnished to a qualifying individual under 
a group health plan, such plan shall ensure that--
            ``(1) the financial requirements (as defined in section 
        2726(a)(3) of the Public Health Service Act (42 U.S.C. 300gg-
        26(a)(3))) applicable to such item or service are no more 
        restrictive than the predominant financial requirements applied 
        to substantially all medical and surgical benefits covered by 
        the plan, and that there are no separate cost sharing 
        requirements that are applicable only with respect to such item 
        or service; and
            ``(2) the treatment limitations (as defined in such 
        section) applicable to such item or service are no more 
        restrictive than the predominant treatment limitations applied 
        to substantially all medical and surgical benefits covered by 
        the plan, and that there are no separate treatment limitations 
        that are applicable only with respect to such item or service.
    ``(c) Prohibition on Review of Medical Necessity.--A group health 
plan may not deny or otherwise limit coverage of any item or service 
described in subsection (a) furnished to a qualifying individual on the 
basis of a review of the medical necessity of such item or service by 
such plan or issuer.
    ``(d) Qualifying Individual Defined.--For purposes of this section, 
the term `qualifying individual' means an individual that a physician 
(as defined in section 1861(r) of the Social Security Act (42 U.S.C. 
1395x(r))) or qualified audiologist (as defined in section 
1861(ll)(4)(B) of such Act (42 U.S.C. 1395x(ll)(4)(B))) determines 
meets an indication (including unilateral or bilateral hearing loss) 
for an auditory implant device and external sound processor described 
in subsection (a)(1).''.
            (2) Clerical amendment.--The table of sections for 
        subchapter B of chapter 100 of the Internal Revenue Code of 
        1986 is amended by inserting after the item relating to section 
        9825 the following new item:

``Sec. 9826. Coverage of hearing devices and systems.''.
    (d) Application to Grandfathered Health Plans.--Section 
1251(a)(4)(A) of the Patient Protection and Affordable Care Act (42 
U.S.C. 18011(a)(4)(A)) is amended--
            (1) by striking ``title'' and inserting ``title, or as 
        added after the date of the enactment of this Act)''; and
            (2) by adding at the end the following new clause:
                            ``(v) Section 2799A-11 (relating to hearing 
                        devices and systems).''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply with respect to plan years beginning on or after 
        January 1, 2025.
                                 &lt;all&gt;
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