Legal opinion that the ADA applies to cochlear implant denials

Health plan coverage of cochlear implant services has improved greatly since 1994, largely because of the improvement in coverage under private plans, especially managed care.

According to the Centers for Medicare and Medicaid Services
private payers funded more than half of national health expenditures. About 75 percent of Americans with health insurance are covered by private health plans. Of those, another 40 percent now receive that coverage through a health maintenance organization (HMO), preferred provider organization (PPO), or point-of-service (POS) plan.

The improvement of cochlear implant coverage under managed care plans was largely due to application of the Americans with Disabilities Act
 (ADA) to employer health benefits.

According to 
Cochlear Americas, 90 percent of private health plans provided some level of benefits for cochlear implants as of 2003. A Cochlear survey of surgeons in 2001 revealed that approximately 57 percent of cochlear implant surgeries are covered by private plans.

Reasonable coverage of payment of cochlear implant services by these plans are critical, since they subsidize the large financial losses cochlear implant centers must incur in serving Medicare and Medicaid beneficiaries. Without this subsidization, most cochlear implant programs could not remain viable.

The information linked from this page is meant to identify how existing laws may apply to cochlear implant policies.  Please do not interpret anything on this site to mean that your health plan will definitely cover cochlear implants. Private plan contracts with individual employers may exclude cochlear implant benefits even when the medical policy for that plan provides benefits. Even if your benefit book indicates coverage, always submit a written prior authorization request.

Federal ERISA law requires all health plans to respond to your request in writing. Their response must identify the basis for any denial of coverage, and procedures you can follow to appeal that denial. If they fail to do so, you should contact your respective state insurance commissioner.