…and how do I pay for one?

It can be intimidating to consider a cochlear implant. Cochlear implants are now the standard of care for treating severe and profound hearing loss. They are routinely covered by insurance. This article will help you navigate the financial side of getting a cochlear implant. How much does a cochlear implant cost without insurance? For self-pay patients, we provide tips on how to minimize the cost of a CI.

The Big Picture

In terms of costs, cochlear implants are similar to getting a hip or knee replaced.

The expense of a cochlear implant can be divided between the costs of:

• Surgery and the first year of care
• Ongoing annual maintenance

‍

The out of pocket costs will be different based on your insurance type. There are four types of payment types:

• Private insurance or Medicare Advantage
• Workers’ compensation plans
• Traditional Medicare
• Self-pay patients who pay for everything themselves with cash

The Bottom Line

If you have private insurance, you will likely pay your out of pocket maximum. This varies among insurance plans. How much you pay also depends on where you have your surgery. Surgery can be performed in a hospital or an ambulatory surgery center.

Medicare patients who have a Medigap or supplemental policy will likely pay very little.

Medicare Advantage plans vary widely.

Budgeting the First Year of a Cochlear Implant

Nearly all patients have private insurance or some form of Medicare. The cost of a CI varies depending on the contracted cost. This cost is the price of a service. It is negotiated between the providers and the insurers. Pricing is very complex! The Medicare allowable cost is set by the government. It is considered to be the “rock bottom price”. Other insurance plans are compared against this cost.

Below is a table showing the roadmap to getting a CI. It contains the Medicare and insurance costs of each. There are two main ways to decrease your expenses right off the bat:

• Having your surgery done in a surgery center is much cheaper! You can see that having surgery in a hospital can be several times more expensive! Dr. Ruffin has heard quotes of $150,000 for a CI performed at a hospital.
• If you have an option to change your insurance plan, budgeting for the entire first year of care can help you choose the plan for your hearing health care. This requires that you include monthly premiums into your surgery costs.

‍

Understanding How Insurance Covers Surgery

Patients can save money by choosing where to get surgery. Both insurance and Medicare expect that patients will pay for a portion of surgery. This usually is about 10-20% of the total cost of surgery. Patients are expected to pay the deductible, “co-insurance”, “co-pays”. The total that a patient pays is often capped as the “out of pocket maximum”. See definitions below.

‍

You can see that 20% of surgery is a significant chunk of change.

• Surgery center (20% of $31,856 = 6,371)
• Hospital (20% of $63,712 = 12,742)

This has the greatest consequences for those who have high deductibles or out of pocket maximums.  Some of these can be $8,700 to $17,400!

• Deductible. Amount that must be paid by the patient before an insurance company begins paying. These amounts are usually around $1,500. High deductible plans have lower premiums but higher deductibles (e.g. usually around $5,000).

• Co-Insurance. What you are required to pay even after the deductible has been met.

• Co-Pay. A fixed dollar amount you pay each time you visit certain facilities.

• Out of Pocket Max. The most that you will pay per year for your health care. This is beyond the cost of your premium and is usually around $6,000.
• Premium. The monthly cost of your insurance plan.

Planning Surgery with Private Insurance & Medicare Advantage

There are many types of insurance and privately administered Medicare plans. These private Medicare plans are called “Medicare Advantage” plans. Advantage plans operate more like private insurance.

GETTING COVERAGE FOR SURGERY

It is important to first verify that your insurance plan covers cochlear implants. Insurers may cover cochlear implants. Sometimes they place very conservative “indications”. These indications effectively restrict eligibility for some patients. In other words, you may very well benefit from a CI, but your insurer will say that your hearing is “too good” for them to cover it. In this case, an appeal by your physician’s office may help.

If your plan will not cover a CI, it may be helpful to change to another plan. It will be necessary to plan ahead as enrollment periods vary by plan. You may consult your employer’s Human Resources department, the ACA marketplace insurance plans, Medicare, or your state’s Medicaid plan. Please note that Medicaid plans frequently do not cover CIs.

Sometimes, large employers are self-insured and hire an insurance company to administer their plan. In theses instances, appealing directly to your human resources department can be beneficial.

LOWERING COSTS

First, it is helpful to calculate the entire year of costs. This includes the monthly premiums as well as the anticipated cost of surgery. Be sure to include the monthly insurance premium, deductible, co-pays, and co-insurance. Don’t forget to include the cost of chronic medical conditions. These can affect the choice of insurance plan.

Once you have determined costs for the first year of care, you may find getting a CI unaffordable. Your costs will be lower at a surgery center rather than a hospital (see below for more). You can ask your health insurer where to go for the lowest cost care. If this isn’t helpful, consider shopping on the health insurance market for a plan that is better suited for a CI. This may delay your surgery due to insurance enrollment periods being locked to certain periods during the calendar year.

Bottom line: You will likely hit your out-of-pocket maximum your first year. Back and hip replacement surgeries are COMPARABLE procedures and can help predict your costs.

The deductible is what you pay before the insurance company steps in. The first year of care for a CI will be expensive. Steering away from high deductible plans may be cheaper for the first year of care. In the second year and beyond, a high deductible plan may be financially advisable for an otherwise young, healthy person.

The co-insurance will likely be the biggest factor in paying for your CI surgery. Co-insurance typically ranges from 10-20%. For example, 10% of a $50,000 surgery would be $5,000. A 20% co-insurance would double this to $10,000! This is where the out of pocket maximum cost comes into play. Once your contribution reaches this amount, the insurer pays expenses beyond these costs.

Be sure to include co-pays in your estimate. Co-pays are often assigned to the doctor or surgery center visit. These may range from $25-50 for the doctor and $300-500 for the surgery center. The best way to minimize your co-pay is to have your surgery done at an ambulatory surgery center. Because these centers specialize in just a few surgeries, they are to deliver the same care at a lower cost than a hospital.

SURPRISE BILLING

Remember that surprise billing is now illegal. This billing occurs when some component of surgery such as anesthesia is not in network with your insurance. You can be left with an unexpectedly large bill. Legislation has been passed to ban this practice. It requires that providers bill at a similar rate to in-network providers.

Costs with Traditional Medicare

This refers to traditional Medicare without a Medicare Advantage plan. There are different flavors of Medicare.

• Part A. Hospital Insurance is not typically used. CI surgery is typically outpatient surgery.
• Part B. Outpatient Medical Insurance. This covers CI surgery  in a surgery center. It also covers CI programming when it is done in a doctor’s office.
• Medicare Advantage Plan. Combines Parts A & B into a single plan administered by private insurers. This is not traditional Medicare.

Part B of Medicare covers CI surgery and ongoing costs. Ongoing costs include device programming and new batteries. Patients are responsible for paying the 20% of the Medicare approved amount. Twenty percent of $34,000 is a whopping $6,800. Supplemental Medigap plans pay for this 20% coverage. With Medigap, the out of pocket cost for CI is very small. It is crucial to realize that Medigap plans are not the same as Medicare Advantage plans.

Workers’ Compensation

Some patients lose their hearing from on the job injuries. This can result from accidents or working in noisy industries for many years. If this sounds like you, consider filing a Workers’ Compensation claim. This is a form of insurance that provides medical care for on the job injuries.

Paying for a CI Yourself

How much does a cochlear implant cost without insurance? Self-pay patients pay cash for everything. It’s expensive, but possible. Here are some factors to take into consideration when creating a budget:

• Choose a surgery center instead of a hospital. Hospitals provide a wider array of procedures. This is expensive to maintain. Ambulatory surgery centers focus on just a few procedures. This specialization allows insurers to save money with more efficient care.
• Use the Medicare pricing to negotiate with your providers. This is best done when getting a cash pay quote for surgery. Medicare is considered to be “rock bottom” in pricing. Consider looking elsewhere if your quote is over 150% of Medicare. See above table for general pricing guides.
• Remember that online quotes such as these often do not include the cost of the CI device itself. The cost of the CI device is usually around $25,000. You have little leeway in negotiating this value. Instead, focus on the total costs in a complete quote. This quote for surgery should also include the surgeon and anesthesia fees as well as the surgery center costs.

‍