Amendments to House Bill 656

In addition to conducting a review of House Bill 656, the Council was also asked to review two proposed amendments to House Bill 656: Amendment A0388 and Amendment A0470. If the General Assembly votes to enact House Bill 656, we recommend the adoption of both amendments.

Amendment A0388 provides that diabetes outpatient self-management training and education shall be provided under the supervision of a "certified, registered, or" licensed health care professional (instead of only under the supervision of a "licensed" health care professional as stated in the bill). This provision appears to be very relevant to this legislation. House Bill 656 requires coverage for diabetes outpatient self-management training education; this training and education is typically conducted by a Certified Diabetes Educator. House Bill 656 also requires coverage of medical nutrition therapy which may be provided by a Registered Dietician. Since some benefits proposed under House Bill 656 are provided by health care professionals who are certified and registered, but not licensed, it would be sensible to include this language in the bill.

As amendment A0470 deals with more than one issue, it is more complex. It modifies two issues related to the diabetes portion of this bill and eliminates the coverage for hearing aids. The first diabetes-related issue which amendment A0470 deals with clarifies that the only "orthotics" coverage mandated by House Bill 656 is "orthotics related to the treatment of diabetes illness." This point appears to be valid since the use of orthotics is not limited to the treatment of diabetes. This portion of the amendment is supported by Capital Blue Cross, Independence Blue Cross, and Blue Cross of Northeastern Pennsylvania. Since the major aim of House Bill 656 is to improve coverage and access to supplies for diabetics, it seems appropriate that the coverage for orthotics be limited to orthotics related to the treatment of diabetes.

The second diabetes-related issue in amendment A0470 provides that diabetes outpatient self-management training and education shall be provided "by an individual with expertise in diabetes self-management, training and education". This portion of the amendment is also supported by Capital Blue Cross and Independence Blue Cross. We believe that this issue is also relevant. It seems to be appropriate that diabetes education be conducted by someone with expertise in this area.

With regard to the hearing aid coverage, House Bill 656, Section 634 states, "Hearing Aid Coverage. - Any insurer that underwrites Medicare or Medicaid insurance for insureds residing in this Commonwealth shall provide coverage in such insurance for a hearing aid sold in accordance with Section 403 of the Act of November 24, 1976 (P.L. 1182, No. 262), known as the 'Hearing Aid Sales Registration Law.'" Amendment A0470 would eliminate this language and benefit from the bill.

The only information the Council received supporting the concept of a benefit for hearing aids was from the Pennsylvania Speech-Language-Hearing Association. The Speech-Language-Hearing Association, "supports the availability of hearing aids for those who need them", but have concerns about the language proposed in House Bill 656. They state, "Our concern is that the definition of the term 'coverage' within the bill is not very clear. By this, we mean that in some cases insurers provide an allowance to the consumer toward the purchase of a hearing aid so that if the hearing aid costs more than the allowance, the consumer must make up the difference. In other cases, insurers will state that the covered payment is the total amount that will be provided to the practitioner in full payment for the hearing aid regardless of its cost. Our position is that we would favor the use of an allowance toward the total purchase price, however, we do not believe this bill is clear enough in that regard."

The opposition to the hearing aids coverage portion of the bill is very strong. Highmark, the Managed Care Association, and HealthAmerica are all opposed to this requirement. In addition, the Insurance Federation's support of House Bill 656 is contingent upon the fact that the hearing aid benefits be removed.

Opponents argued that while they are sympathetic to Pennsylvanians who suffer from hearing loss, the cost of providing hearing aids would be substantial. The Managed Care Association estimates that $1,200 is a good approximation for the cost of a hearing aid. According to HealthAmerica, "Mandating hearing aid coverage to insurers that participate in the Medicare program would lead to increased costs to the elderly population of Pennsylvania. ... Forcing yet another benefit mandate on the insurer will increase the premiums the Medicare beneficiaries pay. Many will be unable and/or unwilling to accept this cost in benefit coverage." HealthAmerica continues, "At a time when the Federal government is attempting to control the skyrocketing costs of health care to this population, it seems very unwise to add more benefits that in turn increase costs and reduces the number of individuals able to afford the coverage."

Even if there were no issue of costs, the proposed coverage of hearing aids still has a major area for concern. Highmark stated, "we question the General Assembly's authority to mandate coverage in either the Medicare of Medicaid programs, both of which come under the jurisdiction of the federal government, namely the Health Care Financing Administration." Highmark continues, "Highmark Inc.'s [Medicare services] divisions provide claims processing services to several million Medicare beneficiaries on behalf of HCFA [the Health Care Financing Administration]. ... Technically, [these Medicare services] do not underwrite the Medicare program - we only provide services on behalf of the federal government and are governed solely by their rules and regulations." Highmark concludes, "Highmark sympathizes with the difficulty that some Pennsylvanians may face in paying for hearing aids, we believe that the Pennsylvania General Assembly does not have the authority to mandate coverage for hearing aids in federal health care programs. As stated above, since Highmark technically does not underwrite either the Medicare or Medicaid program, we believe that we would not be subject to this provision, nor would any other insurer in the Commonwealth."

The Council does not recognize a medical connection between the proposed benefits for diabetics and the proposed coverage for hearing aids. We, therefore, suggest that in the interest of passing the beneficial mandate of coverage of diabetic supplies and education, the proposed coverage of hearing aids be removed from House Bill 656. Furthermore, House Bill 656 does not state that if one section (i.e. the hearing aid benefit) of the Act is challenged in court, other portions of the Act (i.e. the diabetes benefits) would still be in effect. Therefore, it is possible that if the bill were to pass as it currently stands, the coverage for diabetic supplies and education could be caught in a long legal battle if the hearing aid mandate were challenged in court.

After reviewing the amendments to House Bill 656, the Council recommends that amendment A0470, as well as amendment A0388 be added to House Bill 656 before final passage.