By Terry Zwolan PhD, Director of the University of Michigan Cochlear Implant Program
Adults and children who do not have insurance coverage for a cochlear implant may wish to explore their ability to participate in a Disability Evaluation under Social Security. The Social Security Administration (SSA) website contains information regarding such evaluations. If someone qualifies for benefits based upon disability, he or she may be eligible to receive health insurance coverage and payment assistance to cover the cost of a cochlear implant through Medicare or Medicaid even if they are under age 65. The following pages from the SSA website provide details:
Social Security Administration Programs
The United States Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act) and the Supplemental Security Income (SSI) program (title XVI of the Act).
Title II provides for payment of disability benefits to individuals who are "insured" under the Act by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals. Title XVI provides SSI payments to disabled individuals (including children under age 18) who have limited income and resources.
Definition of Disability
For all individuals applying for disability benefits under Title II and for adults applying under Title XVI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.
Individuals Receiving Disability Benefits may Qualify for Medicare or Medicaid Coverage
Medicare helps pay hospital and doctor bills of disabled or retired people who have worked long enough under Social Security to be insured for Social Security benefits. It generally covers people who are 65 and over as well as people who have been determined to be disabled and have been receiving benefits for at least 24 months. In general, Medicare pays 80 percent of reasonable charges.
In most States, individuals who qualify for SSI disability payments also qualify for Medicaid. States may refer to the Medicaid program by different names. The program covers all of the approved charges of the Medicaid patient. Medicaid is financed by Federal and State matching funds; eligibility rules are determined by the individual states and they do vary.
Requirements for Disability under SSA
The requirements for disability due to hearing loss are summarized below:
Special Senses and Speech – Adults - Categories of Impairment for Hearing Loss
2.10: Hearing loss not treated with cochlear implantation
A. An average air conduction hearing threshold of 90 decibels or greater in the better ear and an average bone conduction hearing threshold of 60 decibels or greater in the better ear (see 2.00B2c); or
B. A word recognition score of 40 percent or less in the better ear determined using a standardized list of phonetically balanced monosyllabic words (see 2.00B2e).
2.11 Hearing loss treated with cochlear implantation
A. Consider under a disability for 1 year after initial implantation; or
B. If more than 1 year after initial implantation, a word recognition score of 60 percent or less determined using the HINT (see 2.00B3b).
Special Senses and Speech – Children
102.10 Hearing loss not treated with cochlear implantation.
A. For children from birth to the attainment of age 5, an average air conduction hearing threshold of 50 decibels or greater in the better ear (see 102.00B2); or
B. For children from age 5 to the attainment of age 18:
1. An average air conduction hearing threshold of 70 decibels or greater in the better ear and an average bone conduction hearing threshold of 40 decibels or greater in the better ear (see 102.00B2f); or
2. A word recognition score of 40 percent or less in the better ear determined using a standardized list of phonetically balanced monosyllabic words (see 102.00B2f); or
3. An average air conduction hearing threshold of 50 decibels or greater in the better ear and a marked limitation in speech or language (see 102.00B2f and 102.00B5).
102.11 Hearing loss treated with cochlear implantation.
A. Consider under a disability until the attainment of age 5 or for 1 year after initial implantation, whichever is later; or
B. Upon the attainment of age 5 or 1 year after initial implantation, whichever is later, a word recognition score of 60 percent or less determined using the HINT or the HINT-C (see 102.00B3b).
How should someone proceed in determining qualification for this program?
The Disability Determination Process
Most disability claims are initially processed through a network of local Social Security field offices and state agencies (usually called disability determination services, or DDSs). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA's Office of Disability Adjudication and Review (ODAR).
Social Security Field Offices
SSA representatives in the field offices usually obtain applications for disability benefits—in person, by telephone, by mail, or via an online application process. The application and related forms ask for a description of the claimant's impairment(s), names, addresses, and telephone numbers of treatment sources; and other information that relates to the alleged disability. The "claimant" is the person who is requesting disability benefits.
The field office is responsible for verifying nonmedical eligibility requirements, which may include age, employment, marital status, citizenship/residency and Social Security coverage information. For SSI eligibility, the field office verifies income, resources, and living arrangement information. The field office sends the case to a DDS for disability evaluation.
State Disability Determination Services
The DDSs are state agencies responsible for developing medical evidence and rendering the initial determination on whether the claimant is or is not disabled under the law. These state agencies are fully funded by the Federal Government.
Usually the DDS obtains evidence from the claimant's own medical sources. When the evidence is unavailable or insufficient to make a determination, the DDS will arrange a consultative examination (CE) to obtain additional information. The claimant's treating source is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part II, Evidentiary Requirements, for more information about CEs.)
The SSA websites provide a wealth of additional information, including the specific types of audiometric information needed for the Disability Evaluation, test requirements based on the age of the patient, and the necessary qualifications of professionals who can provide the audiometric information that will be reviewed by the SSA. The website also provides YouTube videos that review the Disability Claims process (https://www.youtube.com/watch?v=OvQFbwq4dNA&list=PLGSYaZN04xzFCoEqDlY3n7xgWLh55vvDh ). In many cases, patients who qualify for a cochlear implant based on their best-aided HINT sentence score will also qualify for disability under the SSA requirements. These are valuable resources for CI clinicians as well as patients and family members seeking funding for cochlear implants.