As demand is increasing, more healthcare plans in the US have been offering hearing care benefits as supplementary coverage alongside traditional extra benefits like dental and vision care. This trend has opened up a competitive atmosphere for insurers to offer health care plans that cover things like hearing aids as a way to sell more insurance policies.
To strike this balance between new offerings and profitability, most insurance companies have placed hearing care supplemental plans into managed care structures run by HMOs and PPOs.
Managed care structures dictate a range of limits on treatments based on their reimbursement models, including:
- Which provider is covered
- Hearing aid types covered
- Hearing aid technology covered
These structures provide access to more care options for the policyholder, which can ultimately help lower costs compared to dealing with worsening, untreated conditions. However, the proliferation of these plans has created complex reimbursement structures that affect both audiologists and their patients.
A discussion with Prescription Hearing’s Chief Audiologist Kristen Conners helps us illuminate some of the foundational questions around managed care in hearing care.
“Hearing is completely separate from health insurance, and most people don’t have a great understanding of that. Most audiologists in the Chicagoland area don’t deal with insurance, and people wonder about hearing insurance & whether it covers hearing aids.”
Kristen Conners, Chief Audiologist – Prescription Hearing
With Kristen’s help, we’ll clarify some of the questions around managed care insurance plans and their compatibility with the needs of audiology patients and providers.
What to know: Limits of Managed Care in Audiologist Services
Before managed care, most hearing insurance benefits were direct, giving patients access to either an in-network provider or an out-of-network provider, with some variation on the cost structures involved for each.
Direct benefits were often easier to work with because they were unaffected by strict treatment and equipment (i.e. hearing aids) recommendations, which can be at odds with the best interest of the patient.
While the advent and growth of supplementary hearing coverage yields greater access to care for patients with auditory issues, some unexpected challenges arise, including dealing with coverage limits and navigating the difference between what’s covered by the plan and what’s recommended by audiologists.
Coverage Limits
Hearing professionals are ethically bound to recommend treatments and test regiments based on what is medically necessary and evidence-based, without regard for what’s covered and what isn’t. However, setting limits on coverage in order to control costs can place ethical stress on the relationship between appropriate care and affordable care. Conners describes initial first steps in determining level of coverage:
“We can call and verify through their insurance portal, we learn about their benefits and their options based on the plan.” she said. “Then when they come in with an evaluation, we may help them choose based on testing.”
Occasionally, patients will do their own coverage research, as Conners describes:
“Sometimes the patient will call the insurance first to assure coverage, but then they have to go to the portal to check. Then they sometimes register themselves. But a lot of the time it’s still unclear whether they have coverage.”
Audiologist Help with Coverages
While most audiologists in her service area don’t deal with managed care plans at all, Conners says Prescription Hearing will work with potential patients to figure out a strategy:
“We call and verify through their insurance portal, we learn about their benefits and their options based on the plan. Then when they come in with an evaluation, we may help them choose a path based on testing”
Still, Conners offers recommendations if you’re seeking audiology care or hearing aid coverages under a managed health care plan. The main part of the process is to call your health insurance provider first to get the following information squared away:
- Ensure coverage for the testing AND the device.
- Is the provider in network – the audiologist will provide a National Provider Number (NPI)
- Does the insurance cover costs per ear?
- What is the deductible?
Different Equipment, Different Costs
Since some plans impose limits on reimbursement, the types of hearing aids that are covered and the number of hearing evaluations covered will vary from plan to plan. As a result, patients may find themselves facing higher out-of-pocket costs for services they thought would be covered under their managed care plan.
“People are concerned with the quality and cost of devices.” Conners said. But there is more to hearing aids than just the equipment itself, as Conners continues, “all the testing, fitting and followup are the exact same whether direct billing is allowed or not. After a certain amount of visits, the coverage might reach its limit.”
Health Plan Reimbursement for Audiology Services
Reimbursement and billing are challenges for audiologists dealing with managed care plans. Insurance companies may require orders, referrals and prior authorization before coverage is granted. This excess documentation also contributes to additional administrative overhead, which translates to cost for audiologists. These billing challenges include:
- Navigating complex managed care contracts
- Dealing with delayed reimbursements due to complexity
- Maintaining profitability with lower negotiated reimbursement rates
Of course, practicing audiologists must weigh whether managed care options from HMOs and PPOs coincide with evidence-based, medically necessary treatments on a case-by-case basis and whether the reimbursement tables support their bottom line. Managed care plans can be at odds with both of these crucial audiologist responsibilities.
Other Coverage Options
Besides standard health care packages that have hearing health as a supplement to a main health insurance package, there are other notable options for patients to get coverage for audiology care.
Medicare/Medicaid and its Challenges
Traditional Medicare offers no benefits for hearing health and Medicaid coverage for hearing testing, corrective devices and followup visits vary from state to state.
Medicare Advantage plans are offered by private insurance companies through a contract with the federal government, and often include additional coverages that Medicare Part B doesn’t offer.
However, the coverage allowed varies by plan as well. Some plans will limit the number of hearing exams covered per year, and there will be varying copays for each exam. Other differences between different Medicaid or Medicare Advantage plans may include:
- Different selection of hearing aid model options, including OTC types
- Varying copayments for hearing devices
- Variable coverage for hearing aid fittings, calibrations and repairs
- A range of follow-up appointment coverages
Third-Party Administrators
Third-party administrators (TPAs) partner with insurance companies to deal with reimbursement, pricing and provider network structures. While helpful for insurance companies, they can further complicate the reimbursement process, and they’ll also dictate the types, models of devices and pricing structures covered. Some in the industry are concerned that these administrators’ growing influence will affect the decision making on a clinical level.
State & Federal Employee Programs
While employer based insurance plans most often incorporate a variation of a managed care model, the state of Illinois, where Prescription Hearing is based, provides state employees with a generous hearing care package:
“Some Illinois state employees get reimbursed around $2500 per ear when they buy hearing aids. Depending on where they work, it’s great coverage.” Conners said. “There’s also a federal employee program offering $2500 total every five years, in which we bill Blue Cross Blue Shield direct.”
Consult with Prescription Hearing to learn your options
The team at Prescription Hearing is ready to work with you to find the best solution for your hearing care. Regardless of your health care coverage circumstances, they’ll work with you to find the best services and equipment to meet your clinical needs.
Contact the Audiologists at Prescription Hearing for more information.
Hearing Insurance Managed Care FAQs:
Some quick answers to common questions regarding managed care in audiology:
What’s a typical range of cost savings with insurance?
Anywhere from 30% covered to 100% covered.
What’s the lowest that can be covered with insurance?
About $750 per ear, but it can go up to 100% coverage. Average coverage seen by Prescription Hearing is 30% to 100%
Can an HSA or FSA be used to pay for audiology services?
Yes, because it is a medical expense. Usage of both is a growing trend across the board.
Is Prescription Hearing in my provider network?
It’s best to call to be certain, but Prescription Hearing is in network for most major insurance providers.
