Health Insurance: Reimbursement of Claims

ORS 743A.141
Hearing aids and hearing assistive technology systems


(1)

As used in this section:

(a)

“Hearing aid” means any nondisposable, wearable instrument or device designed to aid or compensate for impaired human hearing and any necessary ear mold, part, attachments or accessory for the instrument or device, except batteries and cords.

(b)

“Hearing assistive technology systems” means devices used with or without hearing aids or cochlear implants to improve the ability of a user with hearing loss to hear in various listening situations, such as being located a distance from a speaker, in an environment with competing background noise or in a room with poor acoustics or reverberation.

(2)

A health benefit plan, as defined in ORS 743B.005 (Definitions), shall provide payment, coverage or reimbursement for:

(a)

One hearing aid per hearing impaired ear if:

(A)

Prescribed, fitted and dispensed by a licensed audiologist with the approval of a licensed physician; and

(B)

Medically necessary for the treatment of hearing loss in an enrollee in the plan who is:

(i)

18 years of age or younger; or

(ii)

19 to 25 years of age and enrolled in a secondary school or an accredited educational institution.

(b)

Ear molds and replacement ear molds:

(A)

Up to four times per plan year for enrollees who are younger than eight years of age; and

(B)

At least once per year for enrollees who are:

(i)

Eight to 18 years of age; or

(ii)

19 to 25 years of age and enrolled in a secondary school or an accredited educational institution.

(c)

One box of replacement batteries per year for each hearing aid.

(d)

Necessary diagnostic and treatment services at least twice per year for enrollees who are younger than four years of age and at least once per year for enrollees who are four years of age or older, including:

(A)

Hearing tests appropriate for an enrollee’s age or developmental need;

(B)

Hearing aid checks; and

(C)

Aided testing.

(e)

Bone conduction sound processors, if necessary for appropriate amplification of the hearing loss.

(f)

Hearing assistive technology systems for an enrollee who is younger than 19 years of age, if necessary for appropriate amplification of the hearing loss.

(3)

An insurer may not impose any financial or contractual penalty upon an audiologist if an enrollee elects to purchase a hearing aid or other device priced higher than the benefit amount by paying the difference between the benefit amount and the price of the hearing aid or other device.

(4)

A health benefit plan shall provide the benefits described in subsection (2)(a), (e) and (f) of this section:

(a)

Every 36 months; or

(b)

For hearing aids, more frequently than every 36 months if modifications to an existing hearing aid will not meet the needs of an enrollee who is:

(A)

Under 19 years of age; or

(B)

19 to 25 years of age and enrolled in a secondary school or an accredited educational institution.

(5)

An insurer must contract with pediatric audiologists in sufficient numbers and geographic locations in this state to comply with ORS 743B.202 (Requirements for insurers offering managed health or preferred provider organization insurance) and 743B.505 (Provider networks).

(6)

Insurance producers shall ensure that enrollees have access to navigators or other assisters to facilitate the diagnosis of hearing loss and needed amplification and ensure that technologies are available to treat hearing loss in enrollees who are 19 years of age or younger. Upon receiving a claim for reimbursement for the diagnosis of hearing loss, an insurer shall provide notice of the coverage limits to the enrollee or to the parent or legal guardian of the enrollee. With respect to enrollees with hearing loss who are younger than 19 years of age, an insurer shall provide educational materials to the parent or legal guardian of the enrollee and shall have a process in place to ensure that appropriate technologies are available.

(7)

The payment, coverage or reimbursement required under this section may be subject to provisions of the health benefit plan that apply to other durable medical equipment benefits covered by the plan, including but not limited to provisions relating to deductibles, coinsurance and prior authorization.

(8)

This section is exempt from ORS 743A.001 (Automatic repeal of certain statutes on individual and group health insurance). [2009 c.553 §2; 2011 c.500 §42a; 2015 c.515 §26; 2018 c.9 §2]
Note: 743A.141 (Hearing aids and hearing assistive technology systems) was added to and made a part of the Insurance Code by legislative action but was not added to ORS chapter 743A or any series therein. See Preface to Oregon Revised Statutes for further explanation.

Source

Last accessed
Jun. 26, 2021