So many of us struggle with insurance coverage when requiring hearing aids. The following is just some helpful information that applies to only some of the insurance companies that may help you when beginning to make contact with your insurance representative. It is very important to remember that our children and adults who are deaf and hard of hearing can not experience a typical life when they can not hear. The technology does exist to help our loved ones get on with their lives and to live happier lives because they can communicate, work, play, live a normal life when they can hear with the help of an assisted hearing device. Please keep in mind that each state’s coverage plan may vary based on how you are insured (by a public company or private/self company), and by which insurance play you have elected for the year. Also, each insurance plan and coverage are subject to change annually along with the costs of insurance increasing and based on the head count that each company has covered. Change is a constant so it is always best to speak directly with a representative from your insurance company, even it you end up making a series of calls trying to speak with multiple representatives to get the best answer.
Tips For Appealing With Your Insurance Company
The current codes that an audiologist will use for submitting a request for a BAHA (bone anchored hearing aid or bone anchored auditory device) are the following:
L8690 (Processor and for surgical supplies for an implant)
L8691 (Replacement processor only for the soft band head band)
L8692 (Audio integrated device without the integration for a soft band head band) * This is the most common code used for requesting a bone conduction processor on a soft band head band (non-implanted/bone anchored)
L8699 (Prosthetic implant NOS (not otherwise specified).
There are many other “surgical codes” in addition to the above that your audiologist will also submit for the billing of the surgery costs.
If your request for a BAHA has been denied or rejected by your insurance company, speak with your audiologist and ask if there is anything he/she can do to help you with your appeal. Sometimes, a simple call to the hearing facilities director can help. Other times, you must begin organizing and gathering paperwork that will help prove your case as to why you or your child absolutely needs a BAHA in order to be able to function in life. You will have to gather supporting documentation that helps show how your child’s hearing can improve with the use of a BAHA, showing that your child is benefiting from wearing an assisted hearing device. Hearing evaluation reports can help document this type of improvement in hearing. If you child has had therapists or is showing speech and communication delays and is falling behind in school, this type of information can be helpful in proving your case as well. Letters from your audiologist and ENT, surgeon, can all help provide support to your case. If you can, ask to speak with someone who has been through this before or is an expert at handling insurance claims and appeals. For example, many of the hearing aid manufacturers have separate departments who can help you with your appeals. It is very important that you go through someone who can help you with your appeal and get it right the first time around. Otherwise, your appeal will just be rejected again. Of course, you can always take things further and continue to fight with legal support.
United Health Care Insurance Coverage
Americans with Disabilities Act (ADA) Protections Expanded for 2009
On Sept. 25, 2008 President Bush signed into law amendments to the Americans with Disabilities Act (ADA) which will significantly broaden protections for employees. Effective Jan. 1, 2009, these changes will impact the ways courts and administrative agencies evaluate whether an individual is disabled for ADA purposes.
- Hearing Aids: Due to a revision to the ADA, effective Oct. 3, 2009 all new and renewing UnitedHealthcare insured customers with more than 15 eligible employees will now have hearing aids covered as part of their benefit plan design, if not already mandated by state law. This coverage is also recommended for UnitedHealthcare ASO groups, however, ultimately benefit coverage and structure is their decision.
- Health Risk Assessment Participation: The EEOC has indicated that an employer requiring an employee to complete a Health Risk Assessment in order to enroll in a group health plan or access health reimbursement accounts is likely a violation of the ADA.
Details on Hearing Aid Coverage
The ADA of 2008 applies to employers’ fringe benefit plans, including fully insured and self-funded (ASO) groups, as well as ASO non-ERISA plans. With limited exceptions, the ADA prohibits such plans from discriminating based upon disability.
Additionally, hearing aids will be included for Small Business groups with 2-14 eligible employees.
This change impacts all UnitedHealthcare platforms. An Operations team has updated UnitedHealthcare’s systems to ensure full compliance with the new provision. All UnitedHealthcare benefit summaries are being updated to support this change. Employers should always consult with their legal counsel to ensure their fringe benefit offerings are in compliance with the ADA.
- Insurance Policies
- HMO Contracts
- ASO Plans (potentially)
- ASO Non-ERISA (potentially)
Changes in interpretation of the ADA result in the following additional benefits:
- Benefits are provided for hearing aids required for the correction of a hearing impairment and for charges for associated fitting and testing.
- Benefits for hearing aids are subject to payment requirements (co-payment, co-insurance, deductible and out-of-pocket maximums) and annual limits that mirror those applicable to Durable Medical Equipment and Prosthetic Devices as shown in the Schedule of Benefits. Benefits for hearing aids will never exceed $5,000 per year. Note: ASO accounts may cover this benefit beyond this minimum level as they see fit. ASO accounts are encouraged to consult with their legal counsel to ensure compliance.
Note: Hearing aids are a separate benefit category and not part of Durable Medical Equipment. However, the recommendation is that hearing aid benefit should be paid the same as Durable Medical Equipment, including cost shares and maximums up to a hearing aid annual maximum of $5,000.
- Benefits for bone anchored hearing aids are a covered health service for which benefits are provided under the applicable medical/surgical benefit categories in the certificateonly for covered persons who have either of the following:
- Craniofacial anomalies whose abnormal or absent ear canals preclude the use of a wearable hearing aid.
- Hearing loss of sufficient severity that it would not be adequately remedied by a wearable hearing aid.
Benefits for bone anchored hearing aids are limited to one per covered person during the entire period of time the covered person is enrolled under the policy and include repairs and/or replacement only if the bone anchored hearing aid malfunctions.
Limits and Standards
- Beginning Jan. 1, 2010, UnitedHealthcare’s new standard will be to cover hearing aids, limited to the Durable Medical Equipment dollar limit, or $5,000 per calendar year or policy year, whichever is less.
- Benefits are limited to a single purchase (including repair/replacement) every three years.
Details on Health Risk Assessment Participation
Under Title I of the Americans with Disabilities Act (ADA), once employment begins, an employer may only make disability-related job inquiries and/or require medical examinations in the following circumstances: (1) if they are job-related and consistent with business necessity; (2) in order to follow up on a request for reasonable accommodation; or (3) as part of a voluntary wellness program.
According to the EEOC, a wellness program is voluntary if an employee is neither required to participate nor penalized for non-participation. If a failure or refusal to participate means that the employee is ineligible to enroll in a group health plan or access funds in a health reimbursement arrangement (HRA), the program would not appear to be a voluntary wellness program.
Informal Discussion Letters
The EEOC has issued two informal discussion letters in response to questions regarding whether an employer can require employees to complete a Health Risk Assessment as a condition to be eligible for or to enroll in the employer’s group health care plan or to access funds in an employer-provided HRA. These letters do not constitute an official opinion of the Commission; they are for informational purposes only.
- ADA: Disability-Related Inquiries and Medical Examinations; Health Risk Assessment Letter, http://www.eeoc.gov/eeoc/foia/letters/2009/ada_disability_medexam_healthrisk.html
- ADA: Health Risk Assessments Letter, http://www.eeoc.gov/eeoc/foia/letters/2009/ada_health_risk_assessment.html
Regulations published under GINA on Oct. 7 by the Internal Revenue Service (IRS) and the U.S. Departments of Labor (DOL) and Health and Human Services (HHS) are consistent with the EEOC’s position with respect to Health Risk Assessments. These regulations also restrict the use of a Health Risk Assessment as a condition of enrollment or access to benefits. GINA regulations make clear that genetic information may only be collected as part of a Health Risk Assessment only after enrollment in the group health plan and on a fully voluntary basis (i.e., with no incentives or rewards).
Background on the ADA
The ADA of 1990 is a civil rights law that protects individuals with disabilities from discrimination in the terms, conditions and privileges of employment. This includes fringe benefits provided by employers to employees. The ADA requires that these benefits be provided in a manner that does not discriminate against individuals protected by the ADA (qualified disabled individuals). Qualified disabled individuals include those who have a physical or mental impairment that substantially limits a major life activity.
The Supreme Court originally stated that individuals who could compensate for their disabilities with medications, hearing aids, mobility and other medical devices or prosthetics did not qualify for protection under the ADA. In a complete reversal of this precedent, the new amendments prohibit employers from considering mitigating measures when assessing if an individual is covered under the ADA. With limited exceptions (eyeglasses and contact lenses), employers will now need to evaluate impairments in an unmitigated state when determining whether an individual is substantially limited in a major life activity. Other than minor or temporary impairments, the amendments also prohibit discrimination based on an employer’s alleged perception of an employee’s mental or physical impairment, whether or not that impairment is an actual disability protected by the ADA.
Expansion of Core Major Life Activities
Initially, the law listed such activities as walking, hearing and seeing as core major life activities protected by the ADA. The ADA amendments now add several new activities to this list, which include sleeping, concentrating, thinking and communicating. Additional major life activities also protected by the ADA include the operation of major bodily functions, such as the immune system, normal cell growth, and digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine and reproductive functions.
Immediate Changes Under the New Law
The amendments reject several original court decisions that narrowly construed the term “disability” and the scope of certain general ADA protections. The amendments to the ADA also provide the Equal Employment Opportunity Commission with a chance to issue new regulations that redefine the term substantially limits. The amendments further expand the types of major life activities covered by the law and state that an individual’s status as disabled under the ADA may not be mitigated by the use of medications, aids or devices (other than eyeglasses and contact lenses). The law also takes into consideration an employer’s perception of an employee’s mental or physical impairments, regardless of the extent of the actual impairments.
December 27, 2005
Medicare Reclassifies Auditory Osseointegrated and ABI Devices
The Centers for Medicare and Medicaid Services (CMS) has revised its hearing aid definition so that auditory osseointegrated and auditory brainstem implant (ABI) devices and related services are clearly covered under Medicare as prosthetic devices. The revised policy, published on Nov. 10, resulted from information provided by ASHA’s Health Care Economics Committee and coordinated by Robert Fifer.
Change Request 4038, Pub 100-02, Transmittal 39 of the CMS Manual System, can be found at http://www.cms.hhs.gov/Transmittals/downloads/R39BP.pdf. Effective Dec. 12, the updated Medicare policy states that prosthetic devices now include “osseointegrated implants to the mastoid process of the temporal bone and auditory brainstem devices.” Auditory osseointegrated devices are appropriate for patients with bilateral external ear malformations such as atresia. ABI devices are for patients who are deafened due to bilateral acoustic neuromas or neurofibromas.
A revised definition of hearing aids and auditory implants in the Medicare Benefit Policy Manual, Chapter 16, section 100, describes air conduction and bone conduction hearing aids. Now, it also describes specific devices that replace the function of the middle ear, cochlea, or auditory nerve as prosthetic devices that are payable by Medicare.
CMS limits coverage to those Medicare beneficiaries “when hearing aids are medically inappropriate or cannot be utilized due to congenital malformations, chronic disease, severe sensorineural hearing loss, or surgery.” Medicare carriers are directed to pay for the covered physician services related to these prosthetic devices using current procedural terminology (CPT) and healthcare common procedure coding system (HCPCS) codes. Carriers and intermediaries are further directed to use other codes, when appropriate, should they become available.
The ASHA Health Care Economics Committee has developed and submitted a proposal for a new CPT code that would allow audiologists to bill for the programming of ABI devices. The request for a new code will be presented to the CPT Editorial Panel in February 2006. For more information, contact Steven White, ASHA’s director of health care economics and advocacy, at firstname.lastname@example.org or at 800-498-2071, ext. 4126.
This same article can be accessed at the following link: http://www.asha.org/Publications/leader/2005/051227/051227g.htm
Retired Insured Military Family Coverage
This site may help provide some insight to the individuals and their families who are retired military pertaining to hearing aid coverage. Each state may be different with its coverage policies.
Active Duty Military Coverage through TRICARE
This site may help provide some insight to the individuals and their families who are covered under active military insurance coverage. Each state may be different with its coverage policies.
Although Medicaid may cover an implantable BAHA system, Medicaid may not cover or recognize a BAHA on a soft band head band. Currently, (based on information provided in a meeting with Cochlear Americas on October 25th, 2011), the following US states have coverage through Medicaid:
AZ, CA, ID, IL, IN, KS, LA, MI, MN, NV, NY, OK, TN, TX, UT, VA, WA, WI, and WY. Other sates may also be covered, however, the states mentioned above are confirmed for coverage. Now, as mentioned above, insurance coverage and policies are always changing. For example, shortly following this meeting I found out through one of our group members that the state of Arizona recently cut its entire Kids Care program and AHCCCS program. So, while Baha’s maybe covered under Medicaid, because of the “general cut” only unless a child has an extreme disability will they be covered in AZ. AZ is currently being sued by the federal government at the moment for this cut. Insurance coverage and political and state issues can all affect one another making things become very messy and confusing, in addition to causing change. So, information is always updating and can become outdated very quickly, even though you may be reading something stating one thing, in all actuality, something else of change can still supersede another document. It is always best to speak directly with your insurance representative in order to understand the most current and correct details.