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Texas Insurance Code - INS § 1367.253. Coverage Required

Current as of January 01, 2024 | Updated by Findlaw Staff

(a) A health benefit plan must provide coverage for the cost of a medically necessary hearing aid or cochlear implant and related services and supplies for a covered individual who is 18 years of age or younger.

(b) Coverage required under this section:

(1) must include:

(A) fitting and dispensing services and the provision of ear molds as necessary to maintain optimal fit of hearing aids;

(B) any treatment related to hearing aids and cochlear implants, including coverage for habilitation and rehabilitation as necessary for educational gain;  and

(C) for a cochlear implant, an external speech processor and controller with necessary components replacement every three years;  and

(2) is limited to:

(A) one hearing aid in each ear every three years;  and

(B) one cochlear implant in each ear with internal replacement as medically or audiologically necessary.

(c) Except as provided by Subsections (b) and (d), coverage required under this section:

(1) may not be less favorable than coverage for physical illness generally under the plan;  and

(2) must be subject to durational limits and coinsurance factors no less favorable than coverage provided for physical illness generally under the plan.

(d) Coverage required under this section is subject to any provision that applies generally to coverage provided for durable medical equipment benefits under the plan, including a provision relating to deductibles, coinsurance, or prior authorization.

(e) This section does not apply to a qualified health plan defined by 45 C.F.R. Section 155.20 if a determination is made under 45 C.F.R. Section 155.170 that:

(1) this subchapter requires the plan to offer benefits in addition to the essential health benefits required under 42 U.S.C. Section 18022(b);  and

(2) this state must make payments to defray the cost of the additional benefits mandated by this subchapter.

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Cite this article: FindLaw.com - Texas Insurance Code - INS § 1367.253. Coverage Required - last updated January 01, 2024 | https://codes.findlaw.com/tx/insurance-code/ins-sect-1367-253/

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