Insurance and Reimbursement

Many forms of private and government health insurance (such as Medicare and Medicaid) cover the costs of cochlear implants and the tests and services associated with getting them. However, you should check with your insurance agency for more information.

When you receive a cochlear implant, costs can range from about $50,000 U.S. and up, which may include:

• the doctor and tests to find out if you are a candidate for a cochlear implant
• the cochlear implant device itself
• the surgeon, anesthesiologist, operating room and associated expenses, and sometimes a brief hospital stay
• the fitting and programming of the cochlear implant, training sessions, and rehabilitation services 

Some health care providers may charge a single flat fee for getting a cochlear implant.  Other organizations may bill separately for each part of the process. You should contact your insurance company directly to learn about your particular insurance coverage, billing policies, and payment procedures.

For additional information, you can explore:

• A Step-by-Step Guide to Obtaining Coverage for a Cochlear Implant
• Centers for Medicare and Medicaid Services (CMS)  http://www.cms.hhs.gov/
• Medicaid websites:  http://www.geocities.com/CapitolHill/5974 
• Medicare payments: http://cms.hhs.gov/physicians/mpfsapp/step0.asp

Coverage – for health insurance, coverage involves making sure a health plan or policy pays for the cochlear implant device and related professional services (for example, physician and audiology services).  Usually, you go through a preauthorization process. This means getting a guarantee from the health insurance plan that they will pay for the implant and services before getting treatment. 

Billing – for health insurance, billing involves the process by which health care providers charge, code, and submit their bills (in the form of a claim) to the health insurance company.

Payment –  for the hospital or clinic, payment involves getting the full amount allowed for services given a health plan’s limitations, allowables, deductibles, and co-payments.

 

A Step-by-Step Guide to Obtaining Coverage for the Cochlear Implant
Approximately 90 percent of health insurance companies and managed care plans cover cochlear implants and the tests and services associated with getting them. However, preauthorization of coverage and related services is not automatic. Health insurance policies and health plans, also referred to as "payers," have administrative processes to review coverage issues and make decisions. These processes may be complex and confusing. Understanding your plan's specific process is crucial to getting approval for a cochlear implant. Although each payer may have different reviewing methods, the process of submitting a request is fairly straight-forward. There are five basic steps to requesting a preauthorization of coverage. They are:

Step 1: Researching Coverage
Step 2: Contacting the Payer
Step 3: Writing Letters
Step 4: Following-Up
Step 5: Appealing the Decision

 

Step 1: Researching Coverage

Your health plan can provide you with information that outlines the description of services that are covered and are not covered. Your first step is to read the booklet thoroughly, so you understand you health plan before requesting coverage.

Services: There are six separate services associated with cochlear implantation. Look for benefits to cover the following:

Assessment and evaluation: Most health plans include benefits covering diagnosis of a disease or illness.

Cochlear implant system: Some health plans will specifically cover cochlear implants, some will cover "prosthetics," and a few will specifically exclude the device.

Hospital surgical services: Most health plans cover inpatient and outpatient hospital surgical services.

Surgeon's services: Most health plans cover surgeon's services.

Post-operative audiology services: Most health plans cover rehabilitation, and generally limit, or "cap", post-operative rehabilitation, treatment or therapy. The plan may or may not specifically mention audiology as a covered service.

Repairs and maintenance to external components: Most health plans do not specifically mention coverage for repairs and maintenance for the external components of the cochlear implant. However, not including a benefit does not necessarily mean it is excluded.

In some cases, Medicare and other health insurance groups may cover batteries and other replacement parts (PAS) for the cochlear implant. Replacement parts may include the following:

Batteries, Battery Covers, Cables, Coils, Magnets, Earhooks, etc.  Check with your plan for details.
Information concerning this type of benefit may be found in the durable medical equipment (DME) or medical supplies section of the benefit booklet.
 
Understand the process for making a request for a preauthorization. following the administrative process of your health plan is often critical to obtaining coverage. If you don’t follow the process, they may not pay for a procedure or additional time may be added to the review process.

Questions so you can better understand your plans administrative process may include:

• Do I need to see my primary care physician (PCP)?
• What information should be included in the request?
• In addition to a written request, what kind of medical information and literature should be included with the request?
• To whom do I send the request?
• How long will it take to make a decision?
• Where do I call to get an update on progress?
• If I don't agree with the decision, what are my appeal options?

Continue to contact your health plan if you have additional questions or need clarification. Ask all the questions necessary for you to obtain a clear understanding of what is and is not covered.

If you need additional support, contact your cochlear implant center, or an advocacy group.

 

Step 2: Contacting the Payer

• Provides an opportunity to speak with a health plan representative so you can make a verbal request for coverage. If you are not satisfied with the responses of the person with whom you are speaking, ask to speak with a manager or nurse reviewer. Maybe a written request is not required.
• Provides an opportunity to request the name and address of a specific individual to whom you will send your written request for coverage. Many health plans will provide a general mailbox or post office box number. Push for a name, address and telephone number. If nothing more, get the name and telephone number of the person with whom you spoke.
• If you are covered by a managed care health plan, and have a primary care physician (PCP), make an appointment to see your PCP. Your PCP is the gatekeeper for all referrals, including those to a cochlear implant surgeon or center.
  
  
  

Step 3: Writing Letters

• Preauthorization requests revolve around "medical necessity." This determines if the cochlear implantation is necessary for the treatment or cure of a disease or injury. Your surgeon and audiologist are the individuals qualified to make that decision. Payers insist that letters of medical necessity be written by your physician. You may also write a personal letter for inclusion in the request. It may be helpful to inform the plan of any relevant personal or family issues supporting the need for the cochlear implant.
• Make sure that all the services related to cochlear implants are preauthorized. Health plans may authorize the surgeon's fee or the device without fully understanding that claims for other services (post-operative audiology, for example) will be submitted in the coming months. Make sure they are aware of all the services associated with cochlear implants.

 

Step 4: Following-Up

Once the preauthorization request has been submitted, follow up regularly with your health plan. It is not uncommon for a request to get delayed in the process. Obtain a time frame for a decision from the health plan. Ten days to two weeks is considered a reasonable period of time to review a request for coverage for cochlear implant surgery. If you are quoted a longer time frame, ask why it will take so long. Your cochlear implant center will probably also follow up on the status of the request but do not rely on the center to keep things moving. Take ownership of the process and follow up frequently.

 

Step 5: Appealing the Decision
If the health plan denies the request, appeal the decision. The first step is to determine why the cochlear implant was denied; ask for the denial in writing. Appeals are more effective when in direct response to the specific denial reason. Ask for help with your appeal from your cochlear implant center, and advocacy groups.

The process for appealing the decision may include:

• Writing formal letters of appeal to the health plan. Appeal the denial and respond specifically to the denial reason. Ideally, the surgeon and audiologist should write the letters. The medical necessity of the surgery can best be argued by the surgeon or audiologist. Ask them to help.
• Contacting the health plan. Identify individuals with decision-making responsibility, e.g., medical directors, case managers, claims managers, and utilization review personnel, and get them involved. Ask them for help.
• Contacting your employer's human resources or health benefits representative. Find out how much leverage your employer has with the health plan. Ask them to help.
• Contacting advocacy organizations. Advocacy organizations that support the hearing impaired, cochlear implant candidates and recipients, may be of assistance. Generally, they will not exercise much influence over the health plan. However, they may be able to provide guidance or even connect you with someone who has experienced a similar insurance issue.
• Don't take no for an answer. Persistence is the key to good coverage outcomes.