Ally’s Act

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. 1. Short title This Act may be cited as Ally’s Act 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. 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 . (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. 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) (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 42 U.S.C. 1395x(r) 42 U.S.C. 1395x(ll)(4)(B) . (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. Sec. 726. Coverage of hearing devices and systems. . (c) IRC (1) In general Subchapter B of chapter 100 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) (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 42 U.S.C. 1395x(r) 42 U.S.C. 1395x(ll)(4)(B) . (2) Clerical amendment The table of sections for subchapter B of chapter 100 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) (1) by striking title title, or as added after the date of the enactment of this Act) (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.

Summary: Ally's Act This bill requires private health insurance plans to cover certain hearing devices and systems (e.g., bone-anchored auditory implants) and related items and services. The financial requirements and treatment limitations applicable to such coverage may be no more restrictive than the requirements and limitations for other medical and surgical benefits covered under the plan. Further, a plan may not deny or limit coverage based on the plan's review of the medical necessity of such items or services.