My work has a standard medical coverage policy and a supplemental policy. Both of which have hearing aids sections.
The standard coverage states:
The Program covers the initial hearing aid(s) following Illness or Injury and the exams for their prescription or fitting. In addition to the initial cost of a hearing aid following Illness or Injury, Covered Persons in the Program are eligible for:
• A hearing test/exam when Medically Necessary. Associated office visits, exams and tests are not subject to the maximum dollar amount.
• Reimbursement of up to $1,000 of expenses incurred to purchase a Medically Necessary hearing aid appliance(s) in any rolling 36-month period.*
• Reimbursement for the cost of repair of your hearing aid appliance. The cost for the repair does not count toward the maximum dollar amount.
*Note: The Program will cover the first hearing aid following Illness or Injury, and it is not subject to the maximum dollar amount. Batteries for hearing aid appliances are not eligible for reimbursement. See the How the Rolling 36 - Month Period Is Calculated table for more information.
Special reimbursement rules apply under the Hearing Benefit provisions of the Program. If you do not follow the special rules, you will not be reimbursed. The information that follows explains how to get reimbursed for the following:
• Medically Necessary hearing tests/exams
• Medically Necessary hearing aid appliances
• Repairs to hearing aid appliances
In most cases, your Physician will refer you to an audiologist for your hearing test or to obtain a hearing aid appliance. In general, you will need to obtain a prescription or letter from your Physician to establish the Medical Necessity of the hearing test and/or hearing aid appliance. When you file a Claim for reimbursement, the prescription or letter must accompany your Claim or you will not be reimbursed. If your doctor writes one prescription or referral that covers both a hearing test and hearing aid appliance, you may use the same prescription or letter to obtain reimbursement for both expenses. See the Medical Benefits Administrator table in the “Contact Information” section for information on where to file your Claim.
Your Physician’s office may file your Claim for you. If your Physician’s office does not submit a bill/Claim for your hearing aid appliance purchase, you must submit, along with your bill/Claim, either a prescription or a signed letter from your Physician on his or her letterhead that refers you to an audiologist for testing and/or establishes Medical Necessity for you to purchase a hearing aid appliance.
You are required to submit a bill/Claim for reimbursement for repairs to the hearing aid appliance.
The supplemental policy states:
The Program will reimburse up to $4,000 toward the purchase of hearing aid(s) for routine hearing loss during a rolling 36-month period beginning on the first date of purchase. See the table below for information on how the rolling 36-month period is calculated.
This benefit is available only if you are eligible for Expanded Benefits and the following conditions are met:
• You have exhausted your Base Medical Program benefits for hearing aids or benefits for hearing aids under other health coverage you are enrolled in; or,
• If you have no Base Medical Program benefits or coverage under another health plan to exhaust, then the hearing aid must be determined by an Audiologist to be medically necessary.
This benefit is limited to the cost of the hearing aid. This benefit does not cover any of the following:
• Office visits with an Audiologist
• Diagnostic or routine hearing exams
• Hearing aids provided for cosmetic purposes
• Hearing aid repairs
• Replacement batteries
How the Hearing Aid Benefit Under the Program Is Calculated The Program will reimburse up to $4,000 toward the purchase of a hearing aid(s) not considered for coverage under your Base Medical Program benefits for hearing aids or benefits for hearing aids under other group health coverage you are enrolled in. Any cost share (deductible, co-pay, or coinsurance) paid by the participant in connection with receiving the Base Medical Program benefits for hearing aids or benefits for hearing aids under other group health coverage you are enrolled in is not eligible for reimbursement under the Program. The chart below shows the calculation of the benefit payable under the Program.
My interpretation of the policies as it relates to my situation:
The primary policy covers "illness or injury". I do not have an illness. I do not know if occasional exposure to elevated sound levels and getting old count as injury. If illness and injury are ruled out, does that mean I get zero coverage in the primary policy?
If an Audiologist determines that hearing aids are medically necessary, does the supplemental coverage cover hearing aid devices only?
I have a wellness visit scheduled with my primary care physician and plan on bringing this up with him. How should I proceed? Ask for a prescription to see an Audiologist, a letter as described in the primary policy, let him do an evaluation?
It looks like I may have some coverage, but I need to jump through some hoops. I just want to make sure I'm jumping through the right ones.
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