Coverage

• Managed Care Health Plans
• Preferred Provider Organizations (PPO)
• Federal/State Health Plans: Medicare A, B, C
• Medicaid
• Durable Medical Equipment (DME) Coverage
• Post-operative Rehabilitation Services
• Reimbursement and Bilateral Cochlear Implantation
• Bilateral CI coverage : Medicare • Medicare Advantage Plans • Medicaid

Managed Care Health Plans

• Health Maintenance Organization or HMO.
• Member(s) must select a Primary care Physician (PCP) who manages care, arranges for medically necessary tests and services, and decides when it is appropriate for the patient to seek specialty medical care.
• Some HMO's require a "referral" from the PCP when specialty care is needed. Without a referral, services may not be covered by the health plan and the member may be held financially responsible.
• Member(s) must obtain services within the HMO network (hospital, specialists, durable medical equipment, therapy, etc.) for coverage unless the HMO authorizes services outside of the network.
• HMOs do not usually have a deductible. However, the member(s) is responsible for co-payments.
• Preventive care is usually emphasized in HMOs.
• HMOs typically do not have restrictive plan limitations.

Preferred Provider Organizations (PPO):

• PCP selection is typically not required; however there are exceptions.
• Access to specialty medical care without a PCP referral.
• PPO network is typically larger and in many cases, expand to other states.
• Member(s) has/have coverage outside of the PPO network however, may be responsible for a different deductible and larger co-payment or coinsurance amount.
• Coverage in PPO networks can range from large array of benefits to very streamlined benefit structure.
• Most PPO plans have plan limitations and exclusions.

What are the important elements you should be aware of relative to implantable hearing solutions coverage?

• Review your summary plan and benefit description to determine if implantable hearing solutions are a covered benefit and if so, under what conditions.
• Are there providers (physicians, hospitals, and audiologists) who specialize in implantable hearing solutions?
• For a child with impaired hearing, are there specialists in the HMO or PPO network who work specifically with children?
• Will the health plan cover parts and accessories? If so,
• • What is the coverage for each of these components?
  • What is your out-of-pocket expense associated with parts and accessories?
  • Can you readily obtain parts and accessories in a timely manner?
  • Do you need an authorization for parts and accessories?
• Does the HMO or PPO offer post-operative rehabilitation? If so,
• • How many visits?
  • Is the provider close in proximity?
• Is there coverage for both the implantable hearing device and the surgical procedure? If so,
• • What are your out-of-pocket costs?
• What are the limitations and exclusions?
• Are there waiting periods before coverage is effective?
• Are there pre-existing clauses?
• What are the services/procedures the plan will not cover?

 

Part A -

• Pays for inpatient hospitalizations and in some cases care in skilled nursing facilities.
• Is automatically provided for individuals entitled to Medicare.

Part B -

• Pays for outpatient hospital care, physician care, and durable medical equipment.
• Participation is optional and involves a monthly premium payment.

 

Part C or Medicare Advantage -

Medicare enrollees may elect to have their Medicare benefits assigned to a managed health Plan.

• HMO and PPOs manage Medicare Advantage plans.
• Member must choose either traditional Medicare or a Medicare Advantage Plan.

What are the key differences between traditional Medicare and a Medicare Advantage program?

• Medicare Advantage programs work similarly to commercial HMO and PPOs.
• • HMO - must select a PCP and seek care within a specified network.
• Requires prior authorizations and in some case referrals for certain health care services/procedures.
• Same benefits provided by traditional Medicare but usually enhanced to include many additional preventive services.
• Costs are more controlled.
• • PPO - not required to select a PCP.
• Usually offers benefit coverage for in-network and out-of-network services however, there may be a financial out-of-pocket difference for the member.
• Same traditional Medicare coverage and benefits but usually enhanced to include many additional preventive services.
• May require prior authorizations for certain procedure/services.
• Co-payments and deductibles are generally higher.

Medicaid

• Federal and state government funded programs designed to assist the low-income families and certain aged, blind, or disabled individuals by providing healthcare for themselves and their children.
• • There are 50 separate Medicaid programs.
  • Each state's Medicaid program covers slightly different groups of individuals with slightly different benefits.
• Medicaid managed care organizations.
• • Deferred on a state by state basis.
  • May also enhance benefits to more effectively manage the care of their members.

Durable Medical Equipment (DME) Coverage (see Upgrades and Replacements)

The parts and accessories that are needed to replace external parts from the surgical system kit are generally defined as prosthetics and are therefore generally subject to the health plan requirements applicable to durable medical equipment, prosthetics, orthotics, and supplies ("DMEPOS"), batteries and other replacement parts (i.e. coils, cables, magnets etc.)

• Traditional Medicare -
• • Generally covers parts that are necessary to keep the Cochlear Implant/Baha® system functioning.
  • Other Parts, such as telephone cable, sound processor covers, audio cables, are generally not covered by Medicare.
• Medicare Advantage Plans -
• • Generally covers Parts that traditional Medicare covers.
  • Generally requires a letter from the current treating physician indicating that the parts and accessories requested are still needed for the patient's medical condition in order to prior-authorize benefits.
  • Requires prior authorization.
• State Medicaid Plans -
• • Vary on coverage for parts.
  • May require preauthorization.
  • Follow-up with the specific plan to determine coverage benefits.
  • May require a letter from the ordering physician indicating that the parts and accessories requested are still needed, and/or fall within the guidelines of replacement for that plan in order to prior-authorize benefits.
• Commercial Health Plans -
• • Vary depending on the benefit plan.
  • May or may not require preauthorization.
  • Recommend that the insured contact the customer service number on his/her insurance card to confirm whether and to what extent Parts are covered.

Post-operative Rehabilitation Services

 

The scope of post-operative rehabilitation services can vary somewhat depending upon the individual's needs. And the scope of coverage for rehabilitation services varies as well depending upon the type of insurance plan. If there is a need for rehabilitation services beyond what a particular plan might ordinarily cover, it might be useful to provide a letter from the treating physician explaining the need for additional services for that particular patient. Otherwise, the list below provides the general scope of coverage for post-operative rehabilitation services.

• Traditional Medicare -
• • Allows benefits for medically necessary post-operative rehab following cochlear implantation.
  • Does not require prior-authorization.
• Medicare Advantage Plans -
• • Allows post-operative rehabilitation following cochlear implantation.
  • May require prior authorization prior to services rendered.
• State Medicaid Plans -
• • Coverage and limitations will vary by state.
  • May require a letter explaining the need for the scope of rehabilitation services in order to obtain preauthorization.
• Commercial Health Plans -
• • Generally, they allow benefits for post-operative rehabilitation, however there may be a limit to the number of sessions allowed.
  • Several commercial health plans consider the cochlear implant rehabilitation under the speech therapy benefit and are subject to the speech therapy limitations.
  • Prior authorization may or may not be required for these services.

Reimbursement and Bilateral Cochlear Implantation

The surgeon and the patient may select from two options for bilateral cochlear implantation:

• Simultaneous implantation - both ears implanted during the same surgical session.
• Sequential implantation - cochlear implantation in each ear during separate implantation surgical sessions (can range from weeks to years).

Depending on which option the surgeon and the patient elect, the following factors should be considered:

- Commercial health Plan coverage.

• Does the patient's health insurance cover simultaneous cochlear implantation?
• Ask the patient to review their health plan's "certificate of coverage" provided to them by their health plan to determine benefit coverage.
• Make sure that the health plan will cover the surgery, cochlear implant devices, and post-surgical rehabilitation.
• Check to see if the patient's health plan requires prior authorization of both the surgery and implants.
• Read the health plan's cochlear implantation medical policy to determine if the health plan considers bilateral cochlear implantation " necessary" and in what situations (simultaneous and/or sequential).
• If a cochlear implantation medical policy does not address bilateral implantation, compile a predetermination packet to send to the patient's health plan to determine coverage.
• Make sure the patient understands the financial responsibilities entailed in either options (i.e., deductibles, co-payments, coinsurance).
• Some of the larger commercial health plans cover bilateral cochlear implantation. however, it is important to clearly understand the coverage and payment parameters and their applicability to the individual patient.
• Even though the health plan may have a general coverage position on bilateral cochlear implantation, it does not mean that the patient's individual health benefit plan has the same coverage.
• Please note that coverage does not guarantee payment.
• Surgeons should check with their health plan's contracts and policies to determine applicable payment for either simultaneous and/or sequential surgeries.
• For simultaneous bilateral cochlear implants, most health plans will reimburse outpatient surgical procedures utilizing the Medicare payment methodology (150% of charges, i.e., Medicare pays for the second surgery at 50%).
• If the patient's health plan denies coverage for bilateral cochlear implantation, the surgeon and/or the patient have a right to appeal the health plan's coverage decision.

- Health plan should provide the patient and surgeon information on appeal rights.
- Patient should work with the surgeon to assist in the appeal process.
- Surgeon should prepare a letter of "medical necessity" outlining the patient's need and value for bilateral implantation, copies and results of medical tests, published peer-reviewed Literature supporting bilateral implantation, and detailed patient history applicable to the request.

Medicare

• The current Medicare coverage policy does not clearly delineate whether bilateral cochlear implantation is covered for either simultaneous or sequential surgeries. contact the Medicare Administrator contractors (MACs)/intermediaries/carriers to request a medical coverage policy determination for bilateral coverage.
• Patients who have previously been implanted through their commercial health plan and are now covered by Medicare may be covered for the second cochlear implant through Medicare. However, it is important for the surgeon's office to check with the Medicare Administrator contractors(MACS)/intermediaries/ carriers to request a medical coverage policy determination prior to providing the service.
• Traditional Medicare does not offer an option for predetermination or prior authorization of coverage. Therefore, the only option is to request a policy interpretation.
• Interpretation may vary by MAC and/or intermediary/carrier.
• Medicare reimbursement will vary depending on whether the bilateral implant is simultaneous or sequential.

Medicare Advantage Plans

• Medicare Advantage Plans must offer the same benefits defined by traditional Medicare but often cover additional services.
• Since the traditional Medicare coverage policy does not clearly delineate whether bilateral cochlear implantation is covered, it is best to contact the patient's Medicare Advantage Plan to inquire about benefit and coverage determinations.
• Medicare Advantage Plans may have policies for predetermination of benefits, preauthorization requirements, and appeal processes. check with the patient's Medicare Advantage Plan to explore the options available.

Medicaid

• Coverage for bilateral cochlear implantation is very inconsistent.
• Check with the patient's state Medicaid plan or Medicaid HMO to determine coverage and benefits.
• Few Medicaid programs officially cover bilateral implantation.
• State Medicaid plans and Medicaid HMOs have processes to appeal claims on an individual basis based on medical necessity.
• Prior authorizations of bilateral implantations are required.