Health insurance coverage for cochlear implant services have changed tremendously over the recent years. Many of the commercial health plans and managed care organizations are now providing coverage benefits for the cochlear implant procedure, processor and related services. There are many reasons why insurance companies are becoming more likely to cover the costs for cochlear implantation. These include that education and awareness of cochlear implants have become more widely known and understood. And cochlear implants have been shown to be cost effective in terms of lifetime income for the recipient versus the societal costs of not providing an implant. Furthermore, the outcomes of cochlear implants are quite consistently favorable.
As a candidate for cochlear implant, you should make every effort to check your insurance policy for coverage and to get pre-approval from your insurance company. Most insurance companies will need a letter of medical necessity from the surgeon as part of the pre-approval process. Many times a medical insurance specialist with the surgeon’s office will work on your behalf to obtain insurance authorization for surgery. Cochlear implant manufacturers also have insurance reimbursement specialists to aid in insurance approval. The cochlear implant manufacturer may help guide you through the appeals process in the event of a denial.
Some insurance companies do not list a cochlear implant as a covered benefit. Be sure to check your insurance coverage on prosthetics/orthotics as cochlear implants fall into this category. If your insurance policy covers prosthetics/orthotics requirements, you should be able to get them to cover the cost of your cochlear implant. Make sure to check for language about not covering any hearing related services. You should also make sure your benefits with your insurance carrier do not inaccurately categorize cochlear a implant as a hearing aid; this is commonly known to happen and results in a denial for surgery.
Medicare, TRICARE, the Veteran’s Administration, and all other federal health plans provide coverage for cochlear implants. Vocational rehabilitation, maternal and children’s health services and other combined federal-state programs may also provide benefits.
Even if your insurance company does cover cochlear implants, they may have guidelines you would need to pass in order to be a qualified candidate for cochlear implant. Most of the federal health plans that provide cochlear implant coverage follow the guidelines that Medicare has set forth to determine eligibility. Here are the Medicare guidelines.
Medicare and federal health plans
Since Medicare does not have a prior authorization process to follow, many cochlear implant centers have no problem billing for the first cochlear implant provided you qualify under the Medicare guidelines. But the centers may have patients sign waivers for the second one (bilateral) stating that if for any reason Medicare does not cover the cochlear implant, they will be financially liable. Medicare’s definition is vague, and does not seem to differentiate between unilateral or bilateral coverage. This becomes a problem for many who would like to get a second implant, but are unsure if they should assume the risk of ending up with a huge bill in the event coverage is denied.
For Medicaid recipients, federal law requires that all state Medicaid programs provide coverage for cochlear implants for children under age 21 years old. Coverage for adults varies by state. If you have a Medicaid HMO plan, coverage may differ from that of straight Medicaid. It appears that any type of Medicaid plan requires authorization for cochlear implant services. Many require a referral from your primary care physician.
If you have been denied coverage for a cochlear implant, you should first determine the reason. Get the denial in writing, since your first appeal should be based on reason for denial. Provide your denial details to the cochlear implant manufacturer insurance reimbursement specialists to help you with the appeals process.
A few things to keep in mind when it comes to insurance coverage for cochlear implants:
- Be sure to check with all providers that you will see in the process of obtaining a cochlear implant to ensure that they are ‘in network’ or ‘participating’ with your insurance company to help reduce or minimize your out of pocket costs. Don’t assume that just because your surgeon’s office participates with your insurance that the hospital, anesthesiologist, speech therapist, audiologist, psychologist, radiologist will also be in network with your insurance. You do not want to end up with a surprising bill because you did not know the physician that read your MRI/CT Scan did not participate with your insurance.
- Even if your cochlear implant was authorized/approved, this does not always mean 100% coverage. Check your coverage benefits to figure out any out of pocket costs you may be responsible for. If you have co-insurance or deductible that needs to be met, you will be responsible for those costs as well.
- In the event that you must pay for part of the cost and you are not able to pay that in full, most providers have options to work with you on a payment plan. Be sure to discuss this with your providers first before going ahead and committing to surgery.
- Be informed, and ask questions! If you don’t understand something, don’t hesitate to ask. This holds true for anything along the journey for your cochlear implant.