Hearing Aids for Children

During the 2008 legislation session, SB 57 was passed and requires insurance coverage
for hearing aids for children. This document is published by the Colorado Academy of
Audiology to assist Colorado audiologists with the implementation of this new law.

Effective date – State regulated health insurance policies which are issued or renewed on or after
January 1, 2009, must provide coverage of hearing aids for children under the age of eighteen
years. It may be necessary to contact the insurance company to verify the specific date on which
coverage will be effective. All applicable policies shall provide continuous coverage no later
than December 31, 2009.

What is covered?

• Hearing aids which are “medically necessary to meet the needs of the child according to
  accepted professional standards” are covered. “Medical necessity” is demonstrated
  through a prior authorization process. Children must be examined by a physician and an
  audiologist before the hearing aid is fitted.
• The purchase of the initial hearing aids and replacement hearing aids. New hearing aids
  shall be covered not more frequently than every 5 years.
• However, new hearing aids shall be covered if the existing device cannot be repaired or
  altered to meet the needs of the child.
• Services and supplies, including the initial assessment, fitting, adjustments, and auditory
  training are also to be covered and may be billed separately.
• Coverage is subject to deductibles and co-pay requirements. Such deductible and
  copayments shall be the same levels established for other covered benefits. In order to
  determine actual benefit levels, it is necessary to contract the insurer carrier.
• This hearing aid benefit will NOT apply to the patient’s durable medical equipment
  lifetime maximum.

Insurance networks – Many insurers utilize “provider networks.” Benefits may differ
depending on whether services are provided in- or out-of-network. Regardless of the provider’s
network status, when a policy is issued in Colorado, the insurer must honor an “assignment of
benefits,’ meaning that patients may sign an agreement with the provider that payment will go
directly to the provider. A provider is prohibited from balance billing a patient if such provider
is part of the insured network. Non participating providers may bill the patient for outstanding
balances. Participating in a network often increases the benefits and assures timely payment.
Should an audiologist wish to participate with an insurer’s network, it is necessary to contract the
insurer and make application. Below is contact information for the major Colorado insurers.

What about public programs? Medicaid and Medicare are not subject to this statute. Because
CHP+ is administered as by Colorado insurers, children covered under the CHP+ program will
be subject to the requirement.

Why doesn’t this requirement apply to some non-public plans? Many larger employers are
regulated by the federal government and are not subject to state laws. This federal regulation is referred to by the acronym ERISA (Employee Retirement Income Security Act.)

Upon initiation or renewal of a policy on or after July 1, 2009, insurance companies will include
a new identifier on all member identification cards. This identifier will be the words “CO DOI.”
This identifier will indicate whether the policy is subject to regulation by the Division of
Insurance or ERISA. Only plans identified as regulated by the state are required to comply with
this statute.