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

Medicare:

              Since 1985 Medicare has provided monetary coverage for approximately 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 following criteria:

Adults:  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 be eligible.

Children:  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 maintenance.

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. 

Back

Patient’s Financial Burden:

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.  

Back

Medicaid:

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 coverage.  

   Back

Private Insurance:

Most insurers provide coverage for a significant portion of the implant.  Please view the “Links” page for access to specific coverage benefits for many major insurers.  

   Back


References