Impact of Medicaid on Cochlear Implant Access

Abstract

Objective: The study documented the role of Medicaid in the provision of cochlear implants and identified access barriers due to states’ adopted rules. An historical review of federal legislation provided a basis for evaluating the original Congressional intent and how this national purpose aligns with how state programs are currently operating. Study Design: A SurveyMonkey questionnaire was used to facilitate data collection from 47 clinics across 35 states after an initial inquiry was made to each clinic to determine an appropriate point of contact, generally a cochlear implant audiologist. Respondents were from all regions of the United States and represented a diversity of clinic types of varying program size. Data were collected for two calendar years—2015 and 2016. Results: Medicaid was the funding source for an average of 55% of pediatric surgeries based on 36 US clinics. For the 23 clinics returning information on adults, Medicaid was the health insurer for an average (mean) of 22% of cochlear implants (CI) surgeries; the median was 13%. Four access concerns were identified: 1) equipment replacement and processor upgrade policies; 2) low reimbursement by state Medicaid for cochlear implant surgery and related services; 3) Medicaid Managed Care (MCO) and the complexity these providers can add for a specialized service like CI that is offered at a limited number of facilities; and 4) obtaining authorization for CI surgery and related services. Conclusions: The intent of the 1989 legislative changes in Medicaid was to ensure that children received appropriate healthcare services wherever they lived in the country. What has transpired over the years, vis-à-vis CI, is a Medicaid system that varies depending upon the state's individual rules.

Defining Disparities in Cochlear Implantation through the Social Determinants of Health

“…7,23 From a clinic perspective, one major challenge of Medicaid coverage for CI is the low reimbursement rate throughout the continuum of care from surgery to rehabilitation and may lead to limiting access for these patients. 22 While the racial and ethnic health disparities may be influenced by various determinants, there are long-standing differences in access to and quality of healthcare services in a wide range of health conditions based on race and ethnicity. This racial and ethnic disparity has been demonstrated in adult CI research as patients of non-white racial groups are less likely to undergo CI surgery for cochlear implants despite being eligible candidates.…”

“…Currently, only approximately 60% of the States offer Medicaid coverage for cochlear implantation in adults. 22 Even if CI Medicaid coverage is available, the quality of care that is delivered may be negatively impacted by barriers in obtaining upgraded or replacement equipment, poor reimbursement, limitations in locations of care, limitations in the number of covered appointments, and difficulty in authorization for care. 22 In some states, a patient who received a Medicaid-covered cochlear implant as a child may grow out of service eligibility to receive necessary care once they transfer to adult Medicaid coverage.…”

“…22 Even if CI Medicaid coverage is available, the quality of care that is delivered may be negatively impacted by barriers in obtaining upgraded or replacement equipment, poor reimbursement, limitations in locations of care, limitations in the number of covered appointments, and difficulty in authorization for care. 22 In some states, a patient who received a Medicaid-covered cochlear implant as a child may grow out of service eligibility to receive necessary care once they transfer to adult Medicaid coverage. 22 Furthermore, there is evidence that Medicaid patients are 50% less likely to receive sequential bilateral cochlear implants compared with those who were privately insured.…”

“…22 In some states, a patient who received a Medicaid-covered cochlear implant as a child may grow out of service eligibility to receive necessary care once they transfer to adult Medicaid coverage. 22 Furthermore, there is evidence that Medicaid patients are 50% less likely to receive sequential bilateral cochlear implants compared with those who were privately insured. 23 Furthermore, patients covered by Medicaid were five times more likely to experience post-surgery complications and less likely to comply with follow-up appointments compared with privately insured patients.…”

“…7 23 From a clinic perspective, one major challenge of Medicaid coverage for CI is the low reimbursement rate throughout the continuum of care from surgery to rehabilitation and may lead to limiting access for these patients. 22…”