Section 1 Short title
This Act may be cited as the “Ally’s Act”.
Ally’s Act
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.
Sec. 2 Coverage of hearing devices and systems in certain private health insurance plans
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:
“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 (as defined in subsection (d)):
“(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) where such item or service has been determined to be medically necessary by a physician or qualified audiologist (as such terms are defined in subsection (d)).
“(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).”
ERISA—
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:
“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 (as defined in subsection (d)):
“(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) 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) where such item or service has been determined to be medically necessary by a physician or qualified audiologist (as such terms are defined in subsection (d)).
“(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).”
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:
IRC—
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:
“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 (as defined in subsection (d)):
“(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) 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) where such item or service has been determined to be medically necessary by a physician or qualified audiologist (as such terms are defined in subsection (d)).
“(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).”
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:
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—
by striking “title” and inserting “title, or as added after the date of the enactment of this Act)”; and
by adding at the end the following new clause:
“(v) Section 2799A–11 (relating to hearing devices and systems).”
Effective date— The amendments made by this subsection shall apply with respect to plan years beginning on or after January 1, 2026.