Montana Code Annotated 2021



Part 1. General Provisions

Coverage For Children With Hearing Loss -- Definitions

33-22-128. 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 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 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.

History: En. Sec. 1, Ch. 209, L. 2021.