Medicare participants often have questions regarding vision, dental, and hearing services, and what is covered on their Medicare plan. But today we’re discussing Cochlear implants and Medicare.
Does Medicare cover cochlear implants? In short, yes cochlear implants are covered! However, there are lots of parameters about the specifics. That’s why we’re here!
What are Cochlear Implants?
First of all, what are cochlear implants? You may guess, cochlear has to do with the ears. However, cochlear implants are much more complex than hearing aids.
A cochlear implant device is an electronic instrument, part of which is implanted surgically to stimulate auditory nerve fibers, and part of which is worn or carried by the individual to capture, analyze, and code sound.
The purpose of implanting the device is to provide awareness and identification of sounds and to facilitate communication for people who have moderate to profound hearing impairment.
Who is Eligible for Medicare Coverage of Cochlear Implants?
Guidelines for Cochlear Implant Medicare Coverage
Cochlear implantation may be covered by Medicare for treatment of bilateral pre- or-post-linguistic, sensorineural, moderate-to-profound hearing loss in individuals who demonstrate limited benefit from amplification (typically, hearing aids.)
To put it plainly, you are more likely to have cochlear implants covered by your Medicare plan if hearing aids have not made a significant improvement (there is limited benefit) in your hearing ability. How is this defined? Limited benefit from amplification is defined by test scores of less than or equal to 40% correct in the best-aided listening condition on tape-recorded tests of open-set sentence cognition.
Medicare coverage is provided only for patients who meet all of the following selection guidelines:
- Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from appropriate hearing (or vibrotactile) aids;
- Cognitive ability to use auditory clues and a willingness to undergo an extended program of rehabilitation;
- Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the auditory nerve and acoustic areas of the central nervous system;
- No contraindications to surgery; and
- The device must be used in accordance with Food and Drug Administration (FDA)-approved labeling.
Cochlear implantation may be covered for individuals meeting the selection guidelines above and with hearing test scores of greater than 40% and less than or equal to 60% only when the provider is participating in, and patients are enrolled in, either an FDA-approved category B investigational device exemption clinical trial as defined at 42 CFR 405.201, a trial under the Centers for Medicare & Medicaid (CMS) Clinical Trial Policy as defined at section 310.1 of the National Coverage Determinations Manual, or a prospective, controlled comparative trial approved by CMS as consistent with the evidentiary requirements for National Coverage Analyses and meeting specific quality standards.
Coverage for Beneficiaries with Hearing of 40% or Less
Generally, a cochlear implant is covered by Medicare if you recognize sentences while wearing your hearing aids only 40% of the time or less.
You must also meet all the guidelines below to qualify for Medicare cochlear implant coverage:
- You’ve received a diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit from hearing aids.
- You are able to use auditory clues and have a willingness to undergo a rehabilitation program.
- You have no medical problems that could put you at risk during surgery.
- You have no middle ear infection.
- You have an accessible cochlear lumen that can support an implantation.
- You have no lesions in the auditory nerve and acoustic areas of the central nervous system.
Medicare Coverage for Beneficiaries with Hearing of 41% to 60%
If you score between 41% and 60% on a hearing test, you may be eligible for Medicare coverage only if your provider is participating in an approved cochlear implant clinical trial.
To receive coverage under these circumstances (if you score between 41% and 60% on a hearing test), your provider must participate in one of the following:
- An FDA-approved category B IDE clinical trial
- A trial under the CMS Clinical Trial Policy
- A controlled comparative trial approved by CMS and consistent with the evidentiary requirements for National Coverage Analyses that meets specific quality standards
How Do Cochlear Implants Work?
Cochlear implants are small devices surgically implanted inside your ear to stimulate the auditory nerve with electrical currents. They bypass hair cells inside the ear and directly transmit sounds through multiple electrodes. The purpose of implanting the device is to provide awareness and identification of sounds for people who are moderately to profoundly hearing impaired.
Cochlear implants have four basic parts, each with their own function:
- A microphone, which picks up sounds, worn externally behind the ear.
- An external speech processor, which converts sounds to electrical signals.
- A transmitter and receiver/stimulator, which relay the signals.
- Implanted electrodes, which stimulate the fibers of the auditory nerve.
Cochlear implants are available in single-channel and multi-channel models. According to the Centers for Medicare and Medicaid Services, users will need to return to the implanting center four to five weeks after post-surgery healing to get the speech processor programmed.
The number of visits needed to properly optimize the device depends on several factors, including age and cognitive skills. Because a patient’s response to nerve stimulation may change, long-term follow-up is required after the procedure.
Does Medicare Cover all the Costs of Cochlear Implants?
Medicare and other federal health programs provide at least some coverage for cochlear implants. Cochlear implants are not hearing aids, as mentioned earlier. This is one key difference to understand! Original Medicare does not cover hearing aids.
Original Medicare will pay 80% of the cost for cochlear implants and surgery for those who qualify.
Medicare covers the cochlear implant as well as its accessories such as microphones and batteries. The surgery may include additional coverage from the use of operating microscope to intra-surgical monitoring.
How Much Will You Pay for Cochlear Implants?
If you meet Medicare’s criteria for cochlear implants, you may still owe some money out-of-pocket.
Medicare considers cochlear implants a prosthetic device covered under Medicare Part B.
You will likely owe 20% for the Medicare-approved cost of the device, and the Part B deductible applies.
You may owe less if you have supplement insurance, such as Medicaid or a Medigap policy. If you’re enrolled in a Medicare Advantage plan, check with your plan provider to learn more about its coverage of cochlear implants. Prior authorization may be required.
Cochlear Implant Monitoring
Cochlear implant monitoring — including remapping and reprogramming — as well as rehabilitation following your surgery is usually covered as an outpatient rehabilitation therapy benefit.
Check your specific plan or ask an insurance expert at your surgeon’s office for more information about any out-of-pocket costs for follow-up care and rehabilitation.
As with many complex healthcare procedures and surgeries, the fine print is critically important to understand what Medicare covers and what requirements must be met.
While cochlear implants are less common than hearing aids and other medical devices, they improve the quality of life for many Medicare-aged people. Knowing what your specific Medicare plan covers can make a difference in the quality of your life.
Too many people put off important healthcare appointments because they are worried about their out-of-pocket costs.
Instead of worrying, get a partner who can help you stay informed about your coverage and your options. We are passionate about helping Medicare-age folks understand how the program works and how they can utilize their benefits.
Why Call Medicare Dana?
- As an independent agent, we offer honest advice specific to your situation. We aren’t tied to any insurance carrier so we look at the entire market for you.
- Talking with us costs you nothing. Ever. And that’s a promise.
- We are here to educate. We’ll work with you to help you understand your Medicare plan.
Do you have questions about cochlear implants or another aspect of healthcare? Give us a call today and let us help.