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Affordable Care Act: Pediatric and Young Adult Hearing Services

Hearing-related benefits for children and young adults under the age of 22 are considered essential health benefits as mandated by the federal Affordable Care Act (ACA).  Audiologists and ear, nose and throat providers in our networks received formal notification from Blue Cross and Blue Shield of North Carolina (BCBSNC) of this change in their fee schedule in January 2014, along with modified pricing policies.  This change will be effective May 8, 2014.  

What Is Covered? 

  • The ACA-mandated pediatric and young adult hearing benefits provide coverage for one hearing aid and affiliated supplies/services for each hearing-impaired ear every 36 months for eligible members under the age of 22.

 

  • Hearing-related services, which include evaluation, fitting and adjustments of hearing aids, replacement of hearing aids, and related supplies such as ear molds should be filed to BCBSNC by the servicing provider when the patient’s medical benefits include the ACA-mandated pediatric and young adult hearing care services.

 

  • Please note that even though these services are considered essential benefits per the ACA, BCBSNC medical policy guidelines will still apply in determining if specific hearing-related devices are services are eligible for coverage.

Who Is Eligible? 

  • The ACA-mandated pediatric and young adult hearing benefits are available for eligible members under the age of 22, if their plan includes the ACA’s essential health benefits.

 

  • These essential health benefits are included in our commercial non-grandfathered plans for individuals and small employer groups.  Large employer groups (ASO accounts) are not required to cover all essential health benefits, although they may choose to purchase our plans that include them.
    • These benefits do apply to the State Health Plan.
    • These benefits do not apply to the Federal Employee Program or our Blue MedicareSM products. Please check benefits for these members to determine what hearing service benefits are available.

 

  • In order to determine whether this benefit applies to a particular member, as well as whether you or the member should submit claims to BCBSNC, you will need to check the member’s eligibility on Blue eSM.

 

Who Is Not Eligible? 

  • Members who have plans that do not include hearing benefits, or who are ineligible for the benefit due to age, will continue to be responsible for payment of these services. 
    • This ACA essential health benefits does not apply to Federal Employee Program or Blue MedicareSM members. Please check benefits for these members to determine what hearing service benefits are available.

How Do I File? 

  • File for the ACA-mandated pediatric and young adult hearing services if the patient is an eligible member and his or her plan includes the ACA’s essential health benefits. 

 

  • When the fee is based on a percentage of the invoice amount, the invoice amount must be reasonable and the same as what you would charge to the general public.

 

  • BCBSNC will apply health benefits and reimbursement based on the provider’s BCBSNC contract.

 

Questions? 

If you have any questions, please contact the Provider Blue LineSM at-1-800-214-4844, or your BCBSNC Strategic Provider Relationships consultant.