The total expense of having a cochlear implant device implanted is approximately $45,000. This cost includes the costs of preoperative screening and consultation, surgery, the device, postoperative training and implant programming, and maintenance. However, it is important to know that there are many programs such as Medicare, Medicaid and private insurance, that cover most, if not all, of the costs. Nevertheless, the patient still has some associated financial burden.
Detailed Breakdown of Implant Related Costs
Since 1985 Medicare has provided monetary coverage for approximately ⅔
of the total costs associate with
obtaining a cochlear implant. Cochlear
implants are considered to be Durable Medical Equipment (DME) and are reimbursed
as a prosthetic device. Although Medicare traditionally provides coverage
primarily for those greater than 65 years of age, there are some younger
patients who are eligible for Medicare coverage under certain circumstances.
To be eligible for Medicare benefits the potential patients must meet the
Cochlear implants may be covered for adults (over age 18) for
prelinguistically, perilinguistically, and postlinguistically deafened adults.
Adults who have lost their hearing after obtaining language skills must
demonstrate test scores of 30 percent or less on sentence recognition scores
from tape-recorded tests in the patient's best listening condition in order to
Cochlear implants may be covered for prelinguistically and
postlinguistically deafened children ages 2 through 17. Bilateral profound
sensorineural deafness must be demonstrated by the inability to improve on age
appropriate closed-set word identification tasks with amplification
The coverage for the surgery can
be reimbursed under either Part A or Part B of Medicare, partially dependent
upon whether the implantation operation was performed on an inpatient or
outpatient basis. Part A covers the costs of the procedure when performed on an
inpatient basis. Part B provides
benefits for the costs of the procedure when performed on an outpatient setting.
In addition, Part B pays for long-term postoperative care and
Part A Coverage Summary:
Reimbursement is dependant on the
Diagnosis Related Group (DRG) “Major Head and Neck Procedures”. This DRG allots on average $9,000 as a global fee to pay for
all inpatient costs including the cost of surgery, cochlear implant device, and
overnight care. It is important for
patients to know that they are not financially responsible for any costs that
covered by Part A of Medicare, but not in its entirety. The maximum cost that a
patient can incur under Part A is the traditional $768 deductible.
However, Part A does not cover care after 90 days, most notably
audiological postoperative training and programming.
Part B Coverage Summary:
In a manner similar to Part A
reimbursement, Part B of Medicare reimburses the cost of the device through a
lump-sum amount that varies depending on billing code.
On average the reimbursement is $13,162-$17,550.
In addition, the costs of the hospital, surgery, and physician are billed
separately to Medicare. Under Part B coverage patients can be liable for up to
20% of the total hospital charges, but no more (approximately $8,000 at upper
end). This 20% co-payment is the traditional Medicare co-payment. However, steps
are being taken to reduce the potential burden to 20% of the Medicare payments.
Part B also provides coverage for cochlear implant services rendered more then
90 days after surgery. Most
notably, post operative audiologist consultations and the repair or replacement
of the implant components. Audiologist are reimbursed based upon the Medicare
fee schedule, which is currently $90 per hour long consultation.
A patient’s potential financial
burden depends on whether or not their physician is a “Participating” or
“Non-Participating” care giver. A
participating care giver (most physicians) agrees to accept Medicare
reimbursement as total payment without balance billing the patient above the
traditional 20% copayment. However,
non-participating caregivers (most audiologists and hospitals) are allowed to
balance bill patients for non-covered services up to 115% or 95% of the Medicare
fee schedule. It is important to
patients to ask their care providers about their participation status to
minimize potential financial burdens. As
a final Medicare note, patients the final say in deciding which cochlear implant
they wish to have implanted. It is
illegal for a manufacturer or physician to provide any renumeration of
inhibition of the patient’s choice as per the Anti-Kickback Statute.
As of 1994, all states fully
reimburse the cost of the implant to those eligible under the guidelines of each
state’s Medicaid program. There
are slight variations in the process of securing coverage among states. Although
many states do not expressly provided coverage for cochlear implants for
children, if a patient’s physician submits a prior authorization request, the
request cannot be denied under the Early
and Periodic Screening, Diagnosis, and Treatment Program (EPSDT).
In addition, similar coverage is available for adults under the Americans
With Disabilities Act (ADA). However,
patients must be eligible for Medicaid coverage as per their states statutes in
order to apply for benefits under the EPSDT or ADA. Please view the “Links”
page for more specific state-by-state benefits eligibility requirements and
provide coverage for a significant portion of the implant. Please view the “Links” page for access to specific
coverage benefits for many major insurers.