Bill Summary – FastDemocracy

67th Legislature                                                                                                     HB 291.1
                                                     HOUSE BILL NO. 291
                                                  INTRODUCED BY M. FUNK
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   A BILL FOR AN ACT ENTITLED: “AN ACT REQUIRING COVERAGE OF AMPLIFICATION DEVICES AND
   RELATED SERVICES FOR CHILDREN WITH HEARING LOSS; AMENDING SECTIONS 2-18-704, 33-31-111,
   AND 33-35-306, MCA; AND PROVIDING A DELAYED EFFECTIVE DATE AND AN APPLICABILITY DATE.”
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   BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MONTANA:
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              NEW SECTION. Section 1.          Coverage for children with hearing loss -- definitions. (1) Health
   insurance coverage sold in the group or individual market in this state must provide coverage for diagnosis and
   treatment of hearing loss for a covered child 18 years of age or younger in accordance with subsection (2).
              (2)   (a) Except as provided in subsection (2)(b), coverage under this section, in addition to diagnosis,
   must include treatment that is:
              (i)   a medical necessity; and
              (ii) prescribed, provided, or ordered by a licensed health care provider to treat hearing loss of the
   covered child.
              (b)   Treatment may not include more than one hearing device with required accessories or
   amplification device with required accessories for each ear every 3 years or as required by an audiologist
   licensed under Title 37, chapter 15.
              (3)   Benefits provided under this section may not be construed as limiting physical health benefits that
   are otherwise available to the covered child.
              (4)   (a) Coverage under this section may be subject to deductibles, coinsurance, and copayment
   provisions and utilization review as provided in Title 33, chapter 32.
              (b)   Special deductible, coinsurance, copayment, or other limitations that are not generally applicable
   to other medical care covered under the plan may not be imposed on the coverage under this section.
              (5)   This section also applies to the state employee group insurance program, the university system
   employee group insurance program, any employee group insurance program of a city, town, school district, or
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   other political subdivision of this state, and any self-funded multiple employer welfare arrangement that is not
   regulated by the Employee Retirement Income Security Act of 1974, 29 U.S.C. 1001, et seq.
              (6)   This section does not apply to disability income, hospital indemnity, medicare supplement,
   accident-only, vision, dental, specific disease, or long-term care policies.
              (7)   As used in this section, the following definitions apply:
              (a)   "Amplification device" means a hearing device, hearing aid, or a wearable, nondisposable,
   nonexperimental instrument or device designed to aid or compensate for impaired human hearing and any
   parts, attachments, or accessories for the instrument or device, including an ear mold but excluding batteries
   and cords.
              (b)   “Generally accepted standards of medical practice” means standards that are based on credible
   scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical
   community, physician specialty society recommendations, the view of physicians practicing in relevant clinical
   areas, and any other relevant factors.
              (c)   "Health care provider" means an individual licensed under Title 37, chapter 3, 15, or 20. A nurse
   practitioner licensed under Title 37, chapter 8, also is a health care provider for the purposes of this section.
              (d)   "Hearing loss" means a disruption in the normal hearing process that may occur in the outer,
   middle, or inner ear, whereby sound waves are not converted to electrical signals and nerve impulses are not
   transmitted to the brain to be interpreted.
              (e)   "Medical necessity" means health care services that a physician, exercising prudent clinical
   judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an
   illness, injury, disease, or its symptoms, and that are:
              (i)   in accordance with generally accepted standards of medical practice;
              (ii) clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered
   effective for the patient’s illness, injury, or disease;
              (iii) not primarily for the convenience of the patient, physician, or other health care provider; and
              (iv) not more costly than an alternative service or sequence of services at least as likely to produce
   equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury, or
   disease.
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              Section 2. Section 2-18-704, MCA, is amended to read:
              "2-18-704.   Mandatory provisions. (1) An insurance contract or plan issued under this part must
   contain provisions that permit:
              (a)   the member of a group who retires from active service under the appropriate retirement provisions
   of a defined benefit plan provided by law or, in the case of the defined contribution plan provided in Title 19,
   chapter 3, part 21, a member with at least 5 years of service and who is at least age 50 while in covered
   employment to remain a member of the group until the member becomes eligible for medicare under the
   federal Health Insurance for the Aged Act, 42 U.S.C. 1395, unless the member is a participant in another group
   plan with substantially the same or greater benefits at an equivalent cost or unless the member is employed
   and, by virtue of that employment, is eligible to participate in another group plan with substantially the same or
   greater benefits at an equivalent cost;
              (b)   the surviving spouse of a member to remain a member of the group as long as the spouse is
   eligible for retirement benefits accrued by the deceased member as provided by law unless the spouse is
   eligible for medicare under the federal Health Insurance for the Aged Act or unless the spouse has or is eligible
   for equivalent insurance coverage as provided in subsection (1)(a);
              (c)   the surviving children of a member to remain members of the group as long as they are eligible for
   retirement benefits accrued by the deceased member as provided by law unless they have equivalent coverage
   as provided in subsection (1)(a) or are eligible for insurance coverage by virtue of the employment of a
   surviving parent or legal guardian.
              (2)   An insurance contract or plan issued under this part must contain the provisions of subsection (1)
   for remaining a member of the group and also must permit:
              (a)   the spouse of a retired member the same rights as a surviving spouse under subsection (1)(b);
              (b)   the spouse of a retiring member to convert a group policy as provided in 33-22-508; and
              (c)   continued membership in the group by anyone eligible under the provisions of this section,
   notwithstanding the person's eligibility for medicare under the federal Health Insurance for the Aged Act.
              (3)   (a) A state insurance contract or plan must contain provisions that permit a legislator to remain a
   member of the state's group plan until the legislator becomes eligible for medicare under the federal Health
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   Insurance for the Aged Act if the legislator:
              (i)   terminates service in the legislature and is a vested member of a state retirement system provided
   by law; and
              (ii) notifies the department of administration in writing within 90 days of the end of the legislator's
   legislative term.
              (b)   A former legislator may not remain a member of the group plan under the provisions of subsection
   (3)(a) if the person:
              (i)   is a member of a plan with substantially the same or greater benefits at an equivalent cost; or
              (ii) is employed and, by virtue of that employment, is eligible to participate in another group plan with
   substantially the same or greater benefits at an equivalent cost.
              (c)   A legislator who remains a member of the group under the provisions of subsection (3)(a) and
   subsequently terminates membership may not rejoin the group plan unless the person again serves as a
   legislator.
              (4)   (a) A state insurance contract or plan must contain provisions that permit continued membership
   in the state's group plan by a member of the judges' retirement system who leaves judicial office but continues
   to be an inactive vested member of the judges' retirement system as provided by 19-5-301. The judge shall
   notify the department of administration in writing within 90 days of the end of the judge's judicial service of the
   judge's choice to continue membership in the group plan.
              (b)   A former judge may not remain a member of the group plan under the provisions of this
   subsection (4) if the person:
              (i)   is a member of a plan with substantially the same or greater benefits at an equivalent cost;
              (ii) is employed and, by virtue of that employment, is eligible to participate in another group plan with
   substantially the same or greater benefits at an equivalent cost; or
              (iii) becomes eligible for medicare under the federal Health Insurance for the Aged Act.
              (c)   A judge who remains a member of the group under the provisions of this subsection (4) and
   subsequently terminates membership may not rejoin the group plan unless the person again serves in a
   position covered by the state's group plan.
              (5)   A person electing to remain a member of the group under subsection (1), (2), (3), or (4) shall pay
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   the full premium for coverage and for that of the person's covered dependents.
              (6)   An insurance contract or plan issued under this part that provides for the dispensing of
   prescription drugs by an out-of-state mail service pharmacy, as defined in 37-7-702:
              (a)   must permit any member of a group to obtain prescription drugs from a pharmacy located in
   Montana that is willing to match the price charged to the group or plan and to meet all terms and conditions,
   including the same professional requirements that are met by the mail service pharmacy for a drug, without
   financial penalty to the member; and
              (b)   may only be with an out-of-state mail service pharmacy that is registered with the board under
   Title 37, chapter 7, part 7, and that is registered in this state as a foreign corporation.
              (7)   An insurance contract or plan issued under this part must include coverage for:
              (a)   treatment of inborn errors of metabolism, as provided for in 33-22-131; and
              (b)   therapies for Down syndrome, as provided in 33-22-139; and
              (c)   treatment for children with hearing loss as provided in [section 1(1) and (2)].
              (8)   (a) An insurance contract or plan issued under this part that provides coverage for an individual in
   a member's family must provide coverage for well-child care for children from the moment of birth through 7
   years of age. Benefits provided under this coverage are exempt from any deductible provision that may be in
   force in the contract or plan.
              (b)   Coverage for well-child care under subsection (8)(a) must include:
              (i)   a history, physical examination, developmental assessment, anticipatory guidance, and laboratory
   tests, according to the schedule of visits adopted under the early and periodic screening, diagnosis, and
   treatment services program provided for in 53-6-101; and
              (ii) routine immunizations according to the schedule for immunization recommended by the
   immunization practice advisory committee on immunization practices of the U.S. department of health and
   human services.
              (c)   Minimum benefits may be limited to one visit payable to one provider for all of the services
   provided at each visit as provided for in this subsection (8).
              (d)   For purposes of this subsection (8):
              (i)   "developmental assessment" and "anticipatory guidance" mean the services described in the
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   Guidelines for Health Supervision II, published by the American academy of pediatrics; and
              (ii) "well-child care" means the services described in subsection (8)(b) and delivered by a physician or
   a health care professional supervised by a physician.
              (9)   Upon renewal, an insurance contract or plan issued under this part under which coverage of a
   dependent terminates at a specified age must continue to provide coverage for any dependent, as defined in
   the insurance contract or plan, until the dependent reaches 26 years of age. For insurance contracts or plans
   issued under this part, the premium charged for the additional coverage of a dependent, as defined in the
   insurance contract or plan, may be required to be paid by the insured and not by the employer.
              (10) Prior to issuance of an insurance contract or plan under this part, written informational materials
   describing the contract's or plan's cancer screening coverages must be provided to a prospective group or plan
   member.
              (11) The state employee group benefit plans and the Montana university system group benefits plans
   must provide coverage for hospital inpatient care for a period of time as is determined by the attending
   physician and, in the case of a health maintenance organization, the primary care physician, in consultation
   with the patient to be medically necessary following a mastectomy, a lumpectomy, or a lymph node dissection
   for the treatment of breast cancer.
              (12) (a) The state employee group benefit plans and the Montana university system group benefits
   plans must provide coverage for outpatient self-management training and education for the treatment of
   diabetes. Any education must be provided by a licensed health care professional with expertise in diabetes.
              (b)   Coverage must include a $250 benefit for a person each year for medically necessary and
   prescribed outpatient self-management training and education for the treatment of diabetes.
              (c) The state employee group benefit plans and the Montana university system group benefits plans
   must provide coverage for diabetic equipment and supplies that at a minimum includes insulin, syringes,
   injection aids, devices for self-monitoring of glucose levels (including those for the visually impaired), test strips,
   visual reading and urine test strips, one insulin pump for each warranty period, accessories to insulin pumps,
   one prescriptive oral agent for controlling blood sugar levels for each class of drug approved by the United
   States food and drug administration, and glucagon emergency kits.
              (d)   Nothing in subsection (12)(a), (12)(b), or (12)(c) prohibits the state or the Montana university
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   group benefit plans from providing a greater benefit or an alternative benefit of substantially equal value, in
   which case subsection (12)(a), (12)(b), or (12)(c), as appropriate, does not apply.
              (e)   Annual copayment and deductible provisions are subject to the same terms and conditions
   applicable to all other covered benefits within a given policy.
              (f) This subsection (12) does not apply to disability income, hospital indemnity, medicare supplement,
   accident-only, vision, dental, specific disease, or long-term care policies offered by the state or the Montana
   university system as benefits to employees, retirees, and their dependents.
              (13) (a) The state employee group benefit plans and the Montana university system group benefits
   plans that provide coverage to the spouse or dependents of a peace officer as defined in 45-2-101, a game
   warden as defined in 19-8-101, a firefighter as defined in 19-