Ally’s Act

II 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 insur- ance 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 Representa- 1 tives of the United States of America in Congress assembled, 2 SECTION 1. SHORT TITLE. 3 This Act may be cited as ‘‘Ally’s Act’’. 4 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00001 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 2 •S 1135 IS SEC. 2. COVERAGE OF HEARING DEVICES AND SYSTEMS IN 1 CERTAIN PRIVATE HEALTH INSURANCE 2 PLANS. 3 (a) PHSA.—Part D of the Public Health Service Act 4 (42 U.S.C. 300gg–111 et seq.) is amended by adding at 5 the end the following new section: 6 ‘‘SEC. 2799A–11. COVERAGE OF HEARING DEVICES AND SYS- 7 TEMS. 8 ‘‘(a) IN GENERAL.—A group health plan and a health 9 insurance issuer offering group or individual health insur- 10 ance coverage shall at a minimum provide coverage for 11 the following items and services furnished to a qualifying 12 individual: 13 ‘‘(1) Auditory implant devices (including audi- 14 tory osseointegrated (bone conduction) implants and 15 cochlear implants) and external sound processors. 16 ‘‘(2) The maintenance of auditory implant de- 17 vices and external sound processors described in 18 paragraph (1). 19 ‘‘(3) Every 5 years, the upgrade (or replace- 20 ment if an upgrade is not available) of auditory im- 21 plant devices and external sound processors de- 22 scribed in paragraph (1). 23 ‘‘(4) Adhesive adapters and softband head- 24 bands. 25 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 3 •S 1135 IS ‘‘(5) The repair of auditory implant devices and 1 external sound processors described in paragraph 2 (1). 3 ‘‘(6) A comprehensive hearing assessment. 4 ‘‘(7) A preoperative medical assessment. 5 ‘‘(8) Surgery relating to the furnishing of such 6 devices and processors (as determined necessary by 7 a physician or qualified audiologist (as such terms 8 are defined for purposes of subsection (d)) treating 9 such individual). 10 ‘‘(9) Postoperative medical visits for purposes 11 of ensuring appropriate recovery from such surgery. 12 ‘‘(10) Postoperative audiological visits for acti- 13 vation and fitting of such devices and processors. 14 ‘‘(11) Aural rehabilitation and treatment serv- 15 ices (as so determined necessary). 16 ‘‘(b) COVERAGE REQUIREMENTS.—In the case of an 17 item or service described in subsection (a) furnished to 18 a qualifying individual under a group health plan or group 19 or individual health insurance coverage, such plan or cov- 20 erage shall ensure that— 21 ‘‘(1) the financial requirements (as defined in 22 section 2726(a)(3)) applicable to such item or serv- 23 ice are no more restrictive than the predominant fi- 24 nancial requirements applied to substantially all 25 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 4 •S 1135 IS medical and surgical benefits covered by the plan or 1 coverage (as applicable), and that there are no sepa- 2 rate cost sharing requirements that are applicable 3 only with respect to such item or service; and 4 ‘‘(2) the treatment limitations (as defined in 5 such section) applicable to such item or service are 6 no more restrictive than the predominant treatment 7 limitations applied to substantially all medical and 8 surgical benefits covered by the plan or coverage (as 9 applicable), and that there are no separate treat- 10 ment limitations that are applicable only with re- 11 spect to such item or service. 12 ‘‘(c) PROHIBITION ON REVIEW OF MEDICAL NECES- 13 SITY.—A group health plan and a health insurance issuer 14 offering group or individual health insurance coverage 15 may not deny or otherwise limit coverage of any item or 16 service described in subsection (a) furnished to a quali- 17 fying individual on the basis of a review of the medical 18 necessity of such item or service by such plan or issuer. 19 ‘‘(d) QUALIFYING INDIVIDUAL DEFINED.—For pur- 20 poses of this section, the term ‘qualifying individual’ 21 means an individual that a physician (as defined in section 22 1861(r) of the Social Security Act) or qualified audiologist 23 (as defined in section 1861(ll)(4)(B) of such Act) deter- 24 mines meets an indication (including unilateral or bilateral 25 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00004 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 5 •S 1135 IS hearing loss) for an auditory implant device and external 1 sound processor described in subsection (a)(1).’’. 2 (b) ERISA.— 3 (1) IN GENERAL.—Subpart B of part 7 of sub- 4 title B of title I of the Employee Retirement Income 5 Security Act of 1974 (29 U.S.C. 1185 et seq.) by 6 adding at the end the following new section: 7 ‘‘SEC. 726. COVERAGE OF HEARING DEVICES AND SYSTEMS. 8 ‘‘(a) IN GENERAL.—A group health plan and a health 9 insurance issuer offering group health insurance coverage 10 shall at a minimum provide coverage for the following 11 items and services furnished to a qualifying individual: 12 ‘‘(1) Auditory implant devices (including audi- 13 tory osseointegrated (bone conduction) implants and 14 cochlear implants) and external sound processors. 15 ‘‘(2) The maintenance of auditory implant de- 16 vices and external sound processors described in 17 paragraph (1). 18 ‘‘(3) Every 5 years, the upgrade (or replace- 19 ment if an upgrade is not available) of auditory im- 20 plant devices and external sound processors de- 21 scribed in paragraph (1). 22 ‘‘(4) Adhesive adapters and softband head- 23 bands. 24 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 6 •S 1135 IS ‘‘(5) The repair of auditory implant devices and 1 external sound processors described in paragraph 2 (1). 3 ‘‘(6) A comprehensive hearing assessment. 4 ‘‘(7) A preoperative medical assessment. 5 ‘‘(8) Surgery relating to the furnishing of such 6 devices and processors (as determined necessary by 7 a physician or qualified audiologist (as such terms 8 are defined for purposes of subsection (d)) treating 9 such individual). 10 ‘‘(9) Postoperative medical visits for purposes 11 of ensuring appropriate recovery from such surgery. 12 ‘‘(10) Postoperative audiological visits for acti- 13 vation and fitting of such devices and processors. 14 ‘‘(11) Aural rehabilitation and treatment serv- 15 ices (as so determined necessary). 16 ‘‘(b) COVERAGE REQUIREMENTS.—In the case of an 17 item or service described in subsection (a) furnished to 18 a qualifying individual under a group health plan or group 19 health insurance coverage, such plan or coverage shall en- 20 sure that— 21 ‘‘(1) the financial requirements (as defined in 22 section 2726(a)(3) of the Public Health Service Act 23 (42 U.S.C. 300gg–26(a)(3))) applicable to such item 24 or service are no more restrictive than the predomi- 25 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 7 •S 1135 IS nant financial requirements applied to substantially 1 all medical and surgical benefits covered by the plan 2 or coverage (as applicable), and that there are no 3 separate cost sharing requirements that are applica- 4 ble only with respect to such item or service; and 5 ‘‘(2) the treatment limitations (as defined in 6 such section) applicable to such item or service are 7 no more restrictive than the predominant treatment 8 limitations applied to substantially all medical and 9 surgical benefits covered by the plan or coverage (as 10 applicable), and that there are no separate treat- 11 ment limitations that are applicable only with re- 12 spect to such item or service. 13 ‘‘(c) PROHIBITION ON REVIEW OF MEDICAL NECES- 14 SITY.—A group health plan and a health insurance issuer 15 offering group health insurance coverage may not deny or 16 otherwise limit coverage of any item or service described 17 in subsection (a) furnished to a qualifying individual on 18 the basis of a review of the medical necessity of such item 19 or service by such plan or issuer. 20 ‘‘(d) QUALIFYING INDIVIDUAL DEFINED.—For pur- 21 poses of this section, the term ‘qualifying individual’ 22 means an individual that a physician (as defined in section 23 1861(r) of the Social Security Act (42 U.S.C. 1395x(r))) 24 or qualified audiologist (as defined in section 25 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 8 •S 1135 IS 1861(ll)(4)(B) of such Act (42 U.S.C. 1395x(ll)(4)(B))) 1 determines meets an indication (including unilateral or bi- 2 lateral hearing loss) for an auditory implant device and 3 external sound processor described in subsection (a)(1).’’. 4 (2) CLERICAL AMENDMENT.—The table of con- 5 tents in section 1 of the Employee Retirement In- 6 come Security Act of 1974 (29 U.S.C. 1001 et seq.) 7 is amended by inserting after the item relating to 8 section 725 the following new item: 9 ‘‘Sec. 726. Coverage of hearing devices and systems.’’. (c) IRC.— 10 (1) IN GENERAL.—Subchapter B of chapter 11 100 of the Internal Revenue Code of 1986 is amend- 12 ed by adding at the end the following new section: 13 ‘‘SEC. 9826. COVERAGE OF HEARING DEVICES AND SYS- 14 TEMS. 15 ‘‘(a) IN GENERAL.—A group health plan shall at a 16 minimum provide coverage for the following items and 17 services furnished to a qualifying individual: 18 ‘‘(1) Auditory implant devices (including audi- 19 tory osseointegrated (bone conduction) implants and 20 cochlear implants) and external sound processors. 21 ‘‘(2) The maintenance of auditory implant de- 22 vices and external sound processors described in 23 paragraph (1). 24 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 9 •S 1135 IS ‘‘(3) Every 5 years, the upgrade (or replace- 1 ment if an upgrade is not available) of auditory im- 2 plant devices and external sound processors de- 3 scribed in paragraph (1). 4 ‘‘(4) Adhesive adapters and softband head- 5 bands. 6 ‘‘(5) The repair of auditory implant devices and 7 external sound processors described in paragraph 8 (1). 9 ‘‘(6) A comprehensive hearing assessment. 10 ‘‘(7) A preoperative medical assessment. 11 ‘‘(8) Surgery relating to the furnishing of such 12 devices and processors (as determined necessary by 13 a physician or qualified audiologist (as such terms 14 are defined for purposes of subsection (d)) treating 15 such individual). 16 ‘‘(9) Postoperative medical visits for purposes 17 of ensuring appropriate recovery from such surgery. 18 ‘‘(10) Postoperative audiological visits for acti- 19 vation and fitting of such devices and processors. 20 ‘‘(11) Aural rehabilitation and treatment serv- 21 ices (as so determined necessary). 22 ‘‘(b) COVERAGE REQUIREMENTS.—In the case of an 23 item or service described in subsection (a) furnished to 24 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 10 •S 1135 IS a qualifying individual under a group health plan, such 1 plan shall ensure that— 2 ‘‘(1) the financial requirements (as defined in 3 section 2726(a)(3) of the Public Health Service Act 4 (42 U.S.C. 300gg–26(a)(3))) applicable to such item 5 or service are no more restrictive than the predomi- 6 nant financial requirements applied to substantially 7 all medical and surgical benefits covered by the plan, 8 and that there are no separate cost sharing require- 9 ments that are applicable only with respect to such 10 item or service; and 11 ‘‘(2) the treatment limitations (as defined in 12 such section) applicable to such item or service are 13 no more restrictive than the predominant treatment 14 limitations applied to substantially all medical and 15 surgical benefits covered by the plan, and that there 16 are no separate treatment limitations that are appli- 17 cable only with respect to such item or service. 18 ‘‘(c) PROHIBITION ON REVIEW OF MEDICAL NECES- 19 SITY.—A group health plan may not deny or otherwise 20 limit coverage of any item or service described in sub- 21 section (a) furnished to a qualifying individual on the basis 22 of a review of the medical necessity of such item or service 23 by such plan or issuer. 24 VerDate Sep 11 2014 22:00 Apr 13, 2023 Jkt 039200 PO 00000 Frm 00010 Fmt 6652 Sfmt 6201 E:\BILLS\S1135.IS S1135 pbinns on DSKJLVW7X2PROD with $$_JOB 11 •S 1135 IS ‘‘(d) QUALIFYING INDIVIDUAL DEFINED.—For pur- 1 poses of this section, the term ‘qualifying individual’ 2 means an individual that a physician (as defined in section 3 1861(r) of the Social Security Act (42 U.S.C. 1395x(r))) 4 or qualified audiologist (as defined in section 5 1861(ll)(4)(B) of such Act (42 U.S.C. 1395x(ll)(4)(B))) 6 determines meets an indication (including unilateral or bi- 7 lateral hearing loss) for an auditory implant device and 8 external sound processor described in subsection (a)(1).’’. 9 (2) CLERICAL AMENDMENT.—The table of sec- 10 tions for subchapter B of chapter 100 of the Inter- 11 nal Revenue Code of 1986 is amended by inserting 12 after the item relating to section 9825 the following 13 new item: 14 ‘‘Sec. 9826. Coverage of hearing devices and systems.’’. (d) APPLICATION TO GRANDFATHERED HEALTH 15 PLANS.—Section 1251(a)(4)(A) of the Patient Protection 16 and Affordable Care Act (42 U.S.C. 18011(a)(4)(A)) is 17 amended— 18 (1) by striking ‘‘title’’ and inserting ‘‘title, or as 19 added after the date of the enactment of this Act)’’; 20 and 21 (2) by adding at the end the following new 22 clause: 23 ‘‘(v) [Text truncated for display. Full text available on Congress.gov.]