Massachusetts Mandates Cleft Palate and Hearing Aid Coverage for Children

09/06/2012

Effective for plan years beginning on or after January 1, 2013, health insurers operating fully-insured health plans in Massachusetts will be required to cover the following new mandated benefits (coverage optional for employers sponsored self-insured plans):

  • Coverage of Cleft Lip/Palate: Insurance carriers will be required to provide coverage for treatment of cleft lip and cleft palate for children, 18 years and younger, if prescribed by a treating physician with a certification that it is medically necessary.
    • Coverage must include benefits for medical, dental, oral and facial surgery, surgical management and follow-up care by oral and plastic surgeons, orthodontic treatment and management, preventative and restorative dentistry to ensure good health and adequate dental structures for orthodontic treatment or prosthetic management therapy, speech therapy, audiology, and nutrition services.
    • Payment for dental or orthodontic treatment not related to the management of the congenital condition of cleft lip and cleft palate are specifically excluded from the mandate.
  • The Children’s Hearing Aid Bill: Insurance carriers will be required to provide coverage for to children, 21 years and younger, for one hearing aid per hearing-impaired ear every 36 months upon written statement of medical necessity by a treating doctor. Coverage is limited to $2,000 per device.
    • Coverage must include all related services prescribed by a licensed audiologist or hearing instrument specialist, including an initial evaluation, fitting and adjustments, and related supplies including ear molds and batteries. These benefits cannot be subject to any greater deductible, coinsurance, copayments or out-of-pocket limits than any other benefits.
    • The insured is permitted to choose a higher priced hearing aid device and “may pay the difference in cost above the two thousand dollar ($2000) limit as provided without any financial or contractual penalty to the insured or to the provider of the hearing aid.

For more information on this topic, contact your WGA Employee Benefits team.