Author Topic: Baha with the insurance marketplace  (Read 5867 times)

cassie d.

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Baha with the insurance marketplace
« on: December 10, 2015, 09:06:31 pm »
Has anyone out there gotten a BAHA with insurance through the Marketplace? We have been trying to get a straight answer from anyone with the insurance companies, but that is almost impossible. They tell us that those benefits will be reveled to us AFTER we sign up. We got bad information last year from an "Insurance Professional" and it left my wife with no BAHA for yet another year. We really would appreciate any insight that any of you may have. Thank You, Cassie D's Husband.
cathy
4.5 tumor de-bunked with surgery Aug. 2013
gamma knife May 2015
Deaf in leftt ear
Moderate facial paralysis left side

arizonajack

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Re: Baha with the insurance marketplace
« Reply #1 on: December 11, 2015, 11:32:24 am »
"Under the Affordable Care Act, health insurers and group health plans will provide the 180 million Americans who have private insurance with clear, consistent and comparable information about their health plan benefits and coverage."

Read more about that where you can see a link to samples of those documents:

https://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/Summary-of-Benefits-and-Coverage-and-Uniform-Glossary.html

Those document samples indicate that a list of covered and excluded items should be addressed by the documents.

Are you not getting those documents when you shop for coverage?

As for the BAHA itself, apparently it is state specific whether hearing aids and/or BAHAs are covered.

Here's a list showing hearing aid coverage (or lack) for all states:

http://www.hearingloss.org/sites/default/files/docs/ACA_StatePlans_HearingAids.pdf

Only 3 states mention BAHA one way or another.

Reply with your state and I'll see if I can find more information.
9/21/16 12mm x 7mm x 5mm
3/23/15 12mm x 5.5mm x 4mm
3/13/14 12mm x 6mm x 4mm
8/1/13 14mm x 5mm x 4mm (Expected)
1/22/13 12mm x 3mm (Gamma Knife)
10/10/12 11mm x 4mm x 5mm
4/4/12 9mm x 4mm x 3mm (Diagnosis)

My story at: http://www.anausa.org/smf/index.php?topic=18287.0

cassie d.

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Re: Baha with the insurance marketplace
« Reply #2 on: December 11, 2015, 05:05:47 pm »
Oh that is so nice of you. We live in Missouri and my husband and I have spent countless hours researching info on coverage for Baha through the marketplace. Last year, I thought we had it nailed down but they denied me again. I've lived for 2 1/2 years without something that could drastically improve the quality of my life. The last straw was a few weeks ago when I was out walking/running with my dogs (no earbuds in or anything) and I didn't hear a car coming up on my deaf side and it got so close, I could feel it brush against my arm. I am just so unbelievably frustrated right now that I want to give up trying to maintain a tiny bit of my old active lifestyle and just fall into a deep depression and sit on the couch and feel sorry for myself. I don't know what's worse- dealing with the leftover's of my life or the financial burden of trying to get the help I need. The doctors and insurance specialist have been no help. My husband and I have had to deal with everything on our own.
cathy
4.5 tumor de-bunked with surgery Aug. 2013
gamma knife May 2015
Deaf in leftt ear
Moderate facial paralysis left side

CHD63

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Re: Baha with the insurance marketplace
« Reply #3 on: December 11, 2015, 06:18:11 pm »
Hi cassie d. and welcome to this forum .....

So sorry you are trapped in an insurance hassle over BAHA coverage!  As I am sure you already know, a bone-anchored hearing assist is considered a prosthetic device, not a hearing aid, because part of it is surgically implanted in your skull.  The issue that comes up here related to insurance coverage is whether your doctor codes it properly to reflect that it is a prosthetic device.

You do not say whether you are going for the Oticon Medical Ponto system or the Cochlear BAHA system.  In either event, I would contact the company (Oticon Medical or Cochlear) directly and inquire as to how the ACA needs to have it coded in order to cover it.  Their insurance people should be able to guide you through this maze, since it is to their distinct advantage for you to have their product.

Let me know how else I might help.

Thoughts and prayers.

Clarice
Right MVD for trigeminal neuralgia, 1994, Pittsburgh, PA
Left retrosigmoid 2.6 cm AN removal, February, 2008, Duke U
Tumor regrew to 1.3 cm in February, 2011
Translab AN removal, May, 2011 at HEI, Friedman & Schwartz
Oticon Ponto Pro abutment implant at same time; processor added August, 2011

arizonajack

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Re: Baha with the insurance marketplace
« Reply #4 on: December 11, 2015, 07:31:18 pm »
Oh that is so nice of you. We live in Missouri and my husband and I have spent countless hours researching info on coverage for Baha through the marketplace.

I'm afraid I don't have good news. According to that state list treatment for hearing loss is covered only for newborns in Missouri. By referring to "benchmark" I conclude that any insurance you buy will have the same exclusions and limitations.

I went to the Marketplace and learned that there are three sources of health insurance coverage:

United Health Care
Coventry
Anthem BCBS

I spent some time drilling through United Health Care's pages trying to find a copy of the health insurance contract or plan booklet. No luck.

Next stop Coventry where I discovered that Coventry does provide complete copies of all of its plan booklets. You can find a list of them at:

http://coventryone.com/individual-health-insurance/missouri/education-and-resources/document-library/index.htm

I picked one at random. Start on Page 68 Excluded Item 27:

27. Hearing Services except as required by law and as specified in the Prosthetics and Preventive Care Services in Section 5, “Covered Services”, including hearing aids for other than newborns, audiometric testing associated with these devices and other hearing devices, tinnitus maskers, and any related purchases, adjustments, or services.

Then go to "Covered Services" Page 54 for an explanation of how Prosthetics are covered:

http://coventryone.com/web/groups/public/@cvty_individual_c1/documents/document/c152323.pdf

I am pretty sure that these provisions are likely to be identical with all three insurance companies.

1 - You will need prior authorization so it's not just a matter of your doctor "coding" the BAHA in such a way as to get it past the claims analyst.

2 - This contract is very specific about what it will and will not cover.

See Page 55. It covers Item 6 - Cochlear Implants (because a cochlear implant is a replacement for a part of the body).

It covers Item 10 - Hearing Aids provided to a newborn for initial amplification following a newborn hearing screening (including any necessary rescreening, audiological assessment and follow-up; see “Preventive Care”) up to one year of age. A hearing aid is an electronic device worn or implanted for the purpose of amplifying sound and assisting the physiological process of hearing.

Note the words "worn or implanted."

Non-covered Prosthetic appliances include:
7 - Hearing aids, fittings and exams for hearing aids for other than newborns

My conclusion after reading the contract is that a BAHA is not covered because the contract defines hearing aid as an electronic device worn or IMPLANTED.

My educated guess is that all three sources of medical insurance in Missouri will have similar or identical limitations.

You can certainly follow Clarice's suggestion about discussing the issue with the BAHA providers but "coding" the procedure in the hope of getting it past the claims analyst isn't going to work because you need pre-approval for prosthetics and that means explaining to the insurance company what the prosthetic is all about before you have it. Once that cat is out of the bag a I suspect that your request for a BAHA will be rejected forthwith.

By the way, my qualifications for this analysis includes a college degree in insurance and 35 years in the insurance industry analyzing all manner of insurance policies.

9/21/16 12mm x 7mm x 5mm
3/23/15 12mm x 5.5mm x 4mm
3/13/14 12mm x 6mm x 4mm
8/1/13 14mm x 5mm x 4mm (Expected)
1/22/13 12mm x 3mm (Gamma Knife)
10/10/12 11mm x 4mm x 5mm
4/4/12 9mm x 4mm x 3mm (Diagnosis)

My story at: http://www.anausa.org/smf/index.php?topic=18287.0

alabamajane

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Re: Baha with the insurance marketplace
« Reply #5 on: December 12, 2015, 10:25:30 am »
Cassie d
Sorry you we having such difficulties getting a hearing device.  Clarice is right in that it is not a hearing aid but a device for people who have no way of hearing without it!

Arizona Jack,, I know you are our insurance expert,, but you didn't mention checking the Anthem BCBS plan,, do you think it may be different? I say that because I have Federal BCBS and it paid for mine. I know all policies are different but BCBS is pretty good to pay usually. And I have no experience with the ACA plans,, they may be much more restrictive. Just a thought.

I hate for anyone who is SSD to be without help if they want it. Just isn't fair,,, and yes I know Jack before you say it,,, NO ONE promised life is fair !  ???

Good luck and let us know how it goes!!
Jane
translab Oct 27, 2011
facial nerve graft Oct 31,2011, eyelid weight removed Oct 2013, eye closes well

BAHA surgery Oct. 2014, activated Dec. 26

arizonajack

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Re: Baha with the insurance marketplace
« Reply #6 on: December 12, 2015, 02:32:42 pm »
Arizona Jack,, I know you are our insurance expert,, but you didn't mention checking the Anthem BCBS plan,, do you think it may be different? I say that because I have Federal BCBS and it paid for mine. I know all policies are different but BCBS is pretty good to pay usually. And I have no experience with the ACA plans,, they may be much more restrictive. Just a thought.

The state list that I posted earlier indicates that the Anthem BCBS plan is the "benchmark" plan which leads me to conclude that the other companies would have the same terms and conditions in their policies. I can't be 100% sure about that.

I went back and looked at the Anthem BCBS coverage in Missouri and found a brochure (not a policy):

http://www.bluekc.com/Content/themes/base/PDF/Plans/BlueOptions2016.pdf

The brochure has limited information and I wouldn't put much stock in any of it without seeing the actual contract.

For example, the pages that list exclusions and limitations say that "repairs and replacement of prosthetics..." are excluded. Well, that doesn't define prosthetics nor does it explain how and if the initial prosthetic is covered.

Then there is a section of Exclusions and Limitations for just Missouri that says "Hearing aids are limited to 1 set every 3 years." Does that mean everybody gets hearing aids or does that just modify the coverage for newborns?

There's no way to know without reading the complete policy contract and I would caution people not to make coverage decisions without seeing the full contract for the plan they are considering. If any insurance company won't provide that, then just walk away from that one.

And, yes, coverage can differ from state to state and can differ between employer sponsored plans and individual plans.
9/21/16 12mm x 7mm x 5mm
3/23/15 12mm x 5.5mm x 4mm
3/13/14 12mm x 6mm x 4mm
8/1/13 14mm x 5mm x 4mm (Expected)
1/22/13 12mm x 3mm (Gamma Knife)
10/10/12 11mm x 4mm x 5mm
4/4/12 9mm x 4mm x 3mm (Diagnosis)

My story at: http://www.anausa.org/smf/index.php?topic=18287.0

cassie d.

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Re: Baha with the insurance marketplace
« Reply #7 on: December 12, 2015, 04:08:05 pm »
Thanks for all the advice. I think my husband and I are leaning towards the Anthem BCBS because this one seems the most Likely to cover the BAHA. We spoke to a rep last night that stated Cochlear implants were covered and if they did happen to deny the BAHA, then maybe we could try stating that they are discrimminating against me for being only deaf in one ear instead of 2. I read through all the insurance literature until my brain feels fried and at this point with just 2 days left to change your plan, I don't know if we can get any closer to understanding all this any better than we do right now. We will just have to keep our fingers crossed and fight like hell. You guys have provided the most useful info so far and I really appreciate it. There's nothing like someone going through this before you to understand what this would mean to me and the quality of my life. Thank you!
cathy
4.5 tumor de-bunked with surgery Aug. 2013
gamma knife May 2015
Deaf in leftt ear
Moderate facial paralysis left side

alabamajane

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Re: Baha with the insurance marketplace
« Reply #8 on: December 12, 2015, 05:57:44 pm »
Sounds like a reasonable plan to me Cassie. I am glad you spoke to a rep too. If he said they cover Cochlear implants, it seems you may stand a good chance of getting a BAHA approved. Like I said, my policy did approve mine and also approved regular hearing aids for my husband.

Best of luck to you! Here's hoping you won't have to fight to get a BAHA approved! Tell them if you walk out in front of a car because you can't hear on that side ( God forbid!),, that they will have a bigger claim filed,,,,

Let us hear!!!  :o

Jane
translab Oct 27, 2011
facial nerve graft Oct 31,2011, eyelid weight removed Oct 2013, eye closes well

BAHA surgery Oct. 2014, activated Dec. 26

 


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