This bulletin addresses the provisions of 2009 Wisconsin Act 14 that created s. 632.895 (16), Wis. Stat., and requires coverage of hearing aids, cochlear implants, and related treatment for infants and children. The Act applies to group and individual policies and to a self-insured health plan of the state or a county, city, town, village, or school district newly issued or renewed beginning after January 1, 2010. You should carefully review the provisions of s. 632.895 (16), Wis. Stat., to determine whether this coverage requirement applies to policies written by your company.
Section 632.895 (16) (a), Wis. Stat., defines terms, including "cochlear implant," "hearing aid," "physician," "self-insured health plan," and "treatment."
Section 632.895 (16) (b) 1, Wis. Stat., provides the following coverage:
- The cost of hearing aids and cochlear implants that are prescribed by a physician or by a licensed audiologist for a child covered under the policy or plan who is under 18 years of age and who is certified as deaf or hearing impaired by a physician or by a licensed audiologist.
- The cost of treatment related to hearing aids and cochlear implants, including procedures for the implantation of cochlear devices, for a child as described above.
- The cost of hearing aids is not required to exceed the cost of one hearing aid per ear per child more often than once every three years.
Section 632.895 (16) (b) 1, Wis. Stat., provides that the coverage may be subject to any cost-sharing provisions, limitations, or exclusions, other than a preexisting condition exclusion, that apply generally under the disability insurance policy or self-insured health plan.
Section 632.895 (16) (c), Wis. Stat., provides that the coverage does not apply to:
- A disability insurance policy that covers only certain specified diseases.
- A disability insurance policy or a self-insured health plan of the state or a county, city, town, village, or school district that provides only limited scope dental or vision benefits.
- A health care plan offered by a limited service health organization or by a preferred provider plan that is not a defined network plan.
- A long-term care insurance policy.
- A Medicare replacement policy or a Medicare supplement policy.
- An individual health benefit plan that is not renewable and that has a specified termination date that, including any extensions that the policyholder may elect without the insurer's consent, is less than 12 months after the original effective date.
Section 632.895 (16), Wis. Stat., first applies to disability insurance policies that are issued or renewed and governmental self-insured health plans that are established, extended, modified, or renewed beginning January 1, 2010. It first applies to policies for employees who are affected by a collective bargaining agreement that are issued or renewed on the earlier of the day on which the collective bargaining agreement expires or the day on which the collective bargaining agreement is extended, modified, or renewed.
A health insurance policy, as defined in the statute, may only include restrictions on hearing aids and/or cochlear implants subject to any cost-sharing provisions, limitations, or exclusions, other than a preexisting condition exclusion, that apply generally under the policy. [s. 632.895 (16) (b) 1, Wis. Stat.] Therefore, policies may not include dollar limits regarding coverage for hearing aids or cochlear implants nor separate co-payment or coinsurance requirements. Health insurance policies that include maximum benefit limits for medical supplies, durable medical equipment (DME) or prosthetic, orthotic or similar benefit limitations may not include in the definition or policy limits or imply that hearing aids or cochlear implants are included in these policy limits.
Health insurance policies may not limit or restrict coverage for infants and children that are certified as deaf or hearing impaired by a physician or by an audiologist by requiring that an infant or child have "severe to profound" deafness. Insurance companies may not administer claims or restrict coverage by unbundling cochlear implant services into device and treatment that results in applying separate co-payments and deductibles, except to the extent there are separate co-payments and deductibles for outpatient, inpatient or surgical services. Any denial, limitation or restriction of coverage of hearing aids, cochlear implants, and related treatment for infants and children under the age of 18 years as not medically necessary is eligible for the grievance and/or independent review process.
Wisconsin requires that policy forms include language describing mandated benefits. Insurance companies must file amended forms or riders for existing forms. Insurance companies must provide a copy of the amended language to each of its policyholders or certificate holders.
Questions regarding this bulletin may be e-mailed to Diane Dambach, at