Template Letter for a State Insurance Commissioner on ACA Marketplace CI Coverage
[Place on Stationery or Type in Name, Address and Phone Number of Clinic}
[Insurance Official Contact Information]
RE: Coverage of Cochlear Implantation in [Name of State]’s EHB Benchmark Plan
Dear [Name of Insurance Commissioner]:
[Introductory Paragraph. Draft a brief paragraph explaining who you are (individual or organization, as appropriate and include credentials), why you are commenting on the Essential Health Benefit (EHB) State Benchmark plan relative to cochlear implantation and/or why you care about access to cochlear implantation. Provide one sentence about the institution you are affiliated with—if you are so affiliated (e.g., hospital, university, private practice) and your concern regarding the recent coverage denial(s). Cite specifics on the language in your state Benchmark plan, particularly if your state plan specifies coverage of CI. State benchmark plans can be accessed via: https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.html. Include the name of the insurance company (or companies) that are denying access to medically necessary care.
Cochlear implantation is a surgical procedure performed in the outpatient or inpatient setting of a hospital. This procedure includes a medical device that provides access to meaningful sound for individuals with severe to profound hearing loss who are not significantly helped by traditional amplification (e.g., hearing aids). Cochlear implantation also requires follow-up audiology and other therapeutic post-implantation care.
One of the required benefits under the Affordable Care Act (ACA) is “rehabilitative and habilitative services and devices” (Section 1302(b)(4) of the ACA). Cochlear implants are considered prosthetic devices that assist an individual with severe to profound hearing loss. Habilitation and rehabilitation therapy services are required for an individual to utilize the sound information provided by the cochlear implant. These services are critical to a CI recipient and are typically covered under the benefit category “rehabilitative and habilitative services and devices.”
Cochlear implants differ significantly from hearing aids. There are stringent candidacy requirements for individuals to qualify for CI coverage. This is a low incidence procedure and there are safeguards to ensure that only people who are qualified candidates and will truly benefit are prescribed this treatment. At my clinic/setting, we provide approximately [insert number] cochlear implants each year to pediatric and adult patients. Approximately 320,000 people worldwide benefit from cochlear implants and about one-third of that number reside in the United States.
Cochlear implantation is cost-effective and is associated with life-changing outcomes. Cochlear implantation consistently ranks among the most cost-effective medical procedures ever reported for children and adults. A seminal work by Johns Hopkins scientists in 2000 found that cochlear implants in children with prelingual deafness results in a net savings of more than $53,000 per child (Cheng, JAMA, 2000).
These savings are particularly important when contrasted with the more than $1 million average expected lifetime cost of a child born with profound hearing loss who does not receive a cochlear implant (Mohr, Int J Tech Assess, 2000). The cost effectiveness of CI in adults is also robust, including in those ages 50-80 years (Francis, Larynoscope, 2002). A recent study found significant increases in adult health in five areas post-cochlear implantation: vitality; physical, mental and emotional health; and social function (Chung et al., Otol Neurotol, 2012).
Cochlear implants are routinely covered by private insurance plans. In fact, the entire continuum of care for cochlear implantation is covered by the majority of private insurance plans. All elements of the intervention (surgery, device, and post-implantation therapies) should be covered in order to achieve maximum outcomes. The ACA requires EHB plans to be equal to a “typical employer plan” and the vast majority of employer plans cover CI. The ACA statute lists a series of mandated benefit categories, including rehabilitative and habilitative services and devices, and requires benefit packages to be designed in a way that does not discriminate against individuals based on disability, expected length of life, or degree of medical dependency. ACA, Section 1302(b)(4).
Two to three of every 1,000 children in the United States are born deaf or hard of hearing and more lose their hearing later in childhood, according to NIH. Research has shown that early intervention is particularly critical for spoken language development in children with hearing loss. Early detection of hearing loss is similar to the early detection of any other disease or illness—it can dramatically change the outcome of one’s prognosis.
For the majority of private insurance plans, bilateral cochlear implantation is now the standard of care. Occasionally, artificial caps in insurance policies preclude a patient from receiving bilateral cochlear implants and this should be avoided as it could impede patient outcomes. Similarly, artificial caps on the number of therapy sessions per year also impede patient adaptation to cochlear implants.
I ask that you please review of the state Benchmark plan and intervene as appropriate with [insert name of insurance company]—and any other insurer who denies coverage of CI and related therapies—so that non-ACA compliant coverage policies are revised to meet the standard set by the state Benchmark plan and to comply with the ACA’s coverage requirements in terms of these important benefits.
Thank you for consideration of my views. If you require additional information or have questions, contact me at: [include your phone number and email address].
Name of institution and location