Cochlear Implantation: Health Insurance and Other Possible Ways of Gaining Coverage
By Donna Sorkin MA, Executive Director of the American Cochlear Implant Alliance and Susan Thomas MA
Cochlear implantation includes a number of necessary medical services and procedures that are provided over time by a team of clinicians. All of these services, as well as the cochlear implant device and related peripherals, are considered part of the medical intervention and are typically covered by health insurance in the United States. These medical services and procedures include candidacy evaluation, hospitals costs inclusive of supplies and medications used during surgery, physician and surgeon’s fees, the cochlear implant device and system kit, and programming and (re)habilitation following the surgery. The majority of cochlear implant cost and aftercare is covered by health insurance. A description of the full continuum of cochlear implant care can be found HERE. This chart may be shared with health insurance officials to aid their understanding of the CI process.
Private health Insurancecoverage for cochlear implantation has improved greatly over the past 15-20 years. Now, over 90% of private employer health insurance plans and managed care organizations provide coverage benefits for the cost of cochlear implant surgery and related services. Medicare, TRICARE, the Veteran’s Administration and other federal health plans all provide coverage for cochlear implants (CI). Plans offered by Affordable Care Act Marketplace Plans generally cover CI. Because of provisions of Federal law governing Medicaid, Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requires that all state Medicaid programs provide CI coverage for children 21 years of age and younger. Medicaid coverage of adults is an optional service and varies by state.
There are state programs that may provide partial or complete coverage for the cost of a cochlear implant for those who meet the state criteria and have no other insurance coverage for cochlear implantation. These include Maternal and Child Health Services (for children) and Vocational Rehabilitation (for adults and college age students). Such programs and coverage vary by state. Vocational rehabilitation coverage may be applicable if an adult does not have health care coverage for a CI and his/her deafness impacts on their employment potential or risk of losing employment. A listing of State Vocational Rehabilitation offices is provided at the following link: http://www.askearn.org/state-vocational-rehabilitation-agencies/
How to Determine If a Health Insurance Plan Covers Cochlear Implantation
If you are determined by a CI center to be an appropriate candidate, check your insurance policy for coverage and obtain pre-approval from your insurance company. Your CI center can help you with this process. If a cochlear implant is not listed as a covered benefit on your plan, check your coverage for prosthetic/orthotics coverage. Cochlear implantation may fall under this category. If you don’t see specific mention of cochlear implant coverage in your policy, check with your insurer directly as there still may be coverage in your policy.
Sometimes insurance companies incorrectly categorize cochlear implants as hearing aids, which can result in an inappropriate denial. Utilize existing materials from this website (www.acialliance.org), from cochlear implant manufacturers, or from your CI center to demonstrate how a cochlear implant differs from a hearing aid. There is still considerable confusion about the difference and you may need to be persistent.
If cochlear implant coverage is denied by your insurance company, you have the right to appeal. Request the denial in writing and then submit an appeal based on the reason for the denial. Seek help from your cochlear implant center with the appeal process.
In addition, the CI manufacturers all offer support in negotiating the process of gaining coverage from health insurers. Individuals skilled in insurance reimbursement will work with you and may even call the insurance company on your behalf. Contact details for for each of the three CI companies currently offering devices in the US are listed in the Resources section of this article.
Disability Benefits for Cochlear Implantation Under Social Security
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. If someone qualifies for benefits based on disability, he or she may be eligible to receive health insurance coverage and payment assistance for a cochlear implant through Medicare or Medicaid even if they are under age 65. For more details, view the ACI Alliance resource An Additional Funding Source for Cochlear Implantation.
For Individuals Without Coverage
ACI Alliance is an advocacy organization working to improve access to cochlear implantation via traditional insurance mechanisms. The organization does not provide grants for cochlear implant surgery, follow-up care or equipment. There are a number of independent social service organizations that may provide some assistance. Typically such aid is limited to US residents. Some organizations to explore include the following:
The Masonic Lodge—check with the organization in your community
Shriners—check with the organization in your community
Outside of the US
If you reside outside of the United States, check to see if there are service organizations in your country. Moose Lodge, Lions Clubs and Shriners—among others—have international chapters and may be able to assist.
Insurance Coverage for (Re)Habilitation Post CI Surgery
Without exception, habilitation must be provided to a child receiving a cochlear implant. Rehabilitation for adults is typically not as intensive but should be considered as part of the CI intervention as it will help an individual reach his or her potential best outcome. An appropriate professional providing such clinical services should have specific training and experience in therapeutic follow-up after cochlear implantation and have an advanced degree in audiology, speech-language pathology or deaf education. Therapeutic services, often referred to as auditory training, are designed to maximize listening skills (as well as language development in children). Auditory training is intended to address and improve sound awareness and discrimination, speech, and learning to apply meaning to sound. Medicare, Medicaid, and most private health plans all have therapy coverage though the criteria and reimbursement policies may differ. Such services are a necessary component of the CI intervention in order to maximize outcomes for CI recipients of all ages. The cost of cochlear implant aftercare is typically covered by health insurance.
There is a perception that insurance does not cover therapy for adults; in general, this is not true. Most health insurance policies do not distinguish between adults and children in coverage. Both Medicaid and Medicare cover therapy follow-up.
You will need to check your policy to determine how many sessions of therapy are covered. If therapy services are denied, you have the right to appeal. Your CI team can help you demonstrate medical necessity for therapy follow-up. Your surgeon or audiologist should write a letter on your behalf demonstrating medical necessity.
Some insurance companies provide for only a limited number of therapy sessions within a time frame of one year. This limitation is a called a therapy cap. If your insurance company has stated therapy caps, and your needs or those of your child exceed the cap limit, you may be able to successfully dispute the limitation. Work with your therapist and CI team to write a report justifying additional sessions beyond the stated therapy cap in your policy.
Some CI centers provide or encourage adult recipients to participate in adult support group meetings, which provide the opportunity to share experiences with other adults. Despite benefits noted by participants, typically such group support is covered poorly, if at all, by health insurance.
Cochlear Implant parts such as coils, cables, microphones, and external magnets may need to be replaced periodically. These parts are all considered to be durable medical equipment (DME). The DME benefit of an insurance plan may cover repairs and replacement parts that are not under warranty. You may need a letter of medical necessity from your surgeon or audiologist to submit to your insurance company for reimbursement of these items.
Batteries (and battery chargers for rechargeable batteries) may also be covered fully or partially by your health insurance. A letter of medical necessity from your physician or audiologist may be needed to document need and medical necessity.
Cochlear implant processors are considered durable medical equipment (DME) by insurance providers. A functioning processor may be eligible for replacement with newer technology depending upon your health insurance plan. Insurance plans may deem a replacement processor medically necessary based upon audiological testing that predicts improved performance with the new technology. It is important to emphasize the difference in hearing ability with the new processor. For example, a new processor might provide improved hearing outcomes in quiet or in noise, provide greater waterproof capability, extend battery life, or expand connectivity to assistive devices allowing better outcome in difficult listening situations or on the telephone.
If your current processor has exceeded its “useful life” (typically five years), your insurance company may provide coverage for new technology. If your insurance does not cover a new processor, you may be able to provide documentation to convince them to do so. Ask your audiologist to help.
Medicare and certain other insurers will replace a processor that is still within the five-year useful life only if the processor has been lost, stolen or damaged beyond repair.
You may want to consider purchasing replacement insurance for your processor if it should be lost or stolen. Check you homeowner’s or rental policy to see if it provides coverage for loss or theft of your sound processor. Check with the manufacturer of your equipment to determine what replacement terms come with the initial warranty.
CI Company Resources
Reimbursement Assistance from CI Company Reimbursement Staff: