Does Insurance Cover Tinnitus? What You Need To Know.

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Insurance and Tinnitus

Whether you struggle with tinnitus, hearing loss, or a combination of both, the best first step is to connect with a medical professional. Depending on your symptoms, there are a variety of specialists that can help, such as your PCP, an ENT Doctor, or an Audiologist. In the United States, that means referrals, co-pays, tests, and possibly some pricey interventions. 

What To Expect With Insurance When You Start The Tinnitus Management Process

The first step with any audiological issue is likely a hearing test. Hearing tests will likely be covered by insurance as long as they are ordered by a physician (this doesn’t have to be ENT, it can be a general practitioner or even a completely unrelated field like gynecology!) and the reason for the test is to determine if there is a change in hearing. This may be based on the patient’s report of a change in hearing OR based on the presence of other symptoms (e.g., tinnitus, pain, otalgia). However hearing tests for the purpose of fitting hearing aids, for example, are not covered by insurance.

Person getting an audiogram

Tinnitus, however, is technically a symptom, and it can be a symptom or side effect of a number of other health conditions – from TMJ to the lingering effects of an ear infection. That means that most clinicians will want to perform a series of tests to rule out other potential culprits.

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Fortunately, an assessment of tinnitus that includes analysis of pitch, loudness, and masking is also typically covered by insurance policies. Hearing tests can also be covered by Medicare with an appropriate order when the test is for the purpose of determining if there is a change in hearing.  If you have questions about coverage for specific tests or procedures, please contact your insurance provider. Your audiologist can provide you with appropriate procedure and diagnosis codes, if you need them.

Moreover, the new 2023 Medicare Fee Schedule for Audiologists has broadened the list of tests and procedures eligible for coverage. Private insurances will usually also cover the same procedures and testing since most private coverage bases fees against Medicare coverage. 

Regardless of what you think you’re covered for, however, be sure to connect with your insurance company to get a complete sense of your coverage.

Does Insurance Cover Hearing Aids for Tinnitus?

Variety of hearing aids

Sometimes, but not always. 

What Should My Coverage Expectations Be?

There is a pretty wide mix of plans that provide specific dollar amounts (e.g., $500 or $1000), specific percentages (e.g., 90% of “the allowable amount”), which does NOT match the audiologist’s price. Oftentimes the only way to know what the coverage for tinnitus hearing aids will be for the patient to submit it, and then wait to find out what is covered/if there are any deductible requirements (e.g., the 90% coverage will ONLY apply after the deductible has been met). This process can often be murky and complicated, but your audiologist can work with you to provide any necessary documentation that is needed by your insurance company.

Third Party Administrators 

There is also another option for purchasing hearing aids, called Third Party Administrators (TPA). Some examples are Amplifon, TruHearing, and Nations Hearing. In these instances, the insurance company has partnered with that specific TPA to offer coverage, and beneficiaries will have to go to an audiologist who is a participating provider for that TPA. 

If I Need Hearing Support From An Audiologist, Should I Select Bundled or Unbundled Services? 

Man getting his ear examined

Bundled Healthcare

In bundled healthcare, audiology services are generally included in the cost of hearing aids. That total cost includes the initial cost of the device, necessary services such as verification, validation, reprogramming, counseling, orientation, appropriate follow-up care, warranties, and check-ins with your clinician. On the plus side, this bundled plan encourages better integration of services and a higher likelihood that patients will connect with their doctors to ensure the devices (and their ear health) are in good shape.

The comprehensiveness of the coverage, however, can also be a drawback since you may or may not actually need or utilize the high level of care, thus you may be paying for services you don’t use.  It is also important to note that devices obtained through TPAs (e.g., Amplifon) will not necessarily have the same level of bundled services that you would receive if you had paid out of pocket. To illustrate this point, patients who receive devices using their Amplifon benefit receive three follow up appointments within the first year or service. Other follow-up care within that time period or after a year are subject to the audiologist’s customary fees.

Unbundled Healthcare

The increasingly popular unbundled model is more of a pay-as-you-go arrangement, wherein you’re only paying for services you use at the time of use. In this scenario, the initial cost of the device is often much lower, but does not include follow-up visits, fittings, or other potentially necessary clinical encounters. There’s certainly a chance those services may be provided as a prix fixe option that’s packaged and priced accordingly, but it’s not a guarantee. That said, when you begin the process of getting hearing aids – especially the first time – it’s hard to know the extent of services and follow-up needs you may have, and a piecemeal approach to paying for those services can add up quickly. This model also has the potential to contribute to underuse of care. If one does not want to pay for services a la carte, they may not pursue them even when they are needed or would be beneficial. 

Additionally, other services that are unrelated to the devices (e.g., counseling, education), but are related to tinnitus, may not be covered by insurance and would be expected to have an out-of-pocket charge to cover the provider’s time.

Takeaways 

Because insurance plans and coverages often change, it’s wise to get a list of covered tests and services when you first start the audiological journey. Certain procedure and diagnosis codes may be necessary for coverage, and you can always ask your audiologist for this list.

Although some aspects of tinnitus care may not be covered by insurance or may include out-of-pocket charges, other aspects are likely to be covered. There are many available treatments for tinnitus, including on-ear devices like hearing aids which may also be helpful in addressing the effects of hearing loss. Although not all insurance plans provide coverage for hearing devices, it is worthwhile to check your specific coverage plan.

That said, when choosing hearing aids, it’s a good idea to select a set that has tinnitus sound generators or tinnitus maskers as part of their suite of options. Most hearing aids do have some kind of built-in sound therapy for tinnitus (from smart phones or other Bluetooth compatible devices) for users to stream their own form of sound therapy), but it’s important to double check since sound therapy, generators, and maskers are especially important for tinnitus. 

Lastly, keep in mind that many insurance companies require you to purchase hearing aids directly through them or a specific network of hearing healthcare providers. Others will allow you to purchase hearing aids through an in-network provider, like an audiologist.

Either way, know what you’re eligible for and what coverages you receive. More often than not, your audiologist will work with you to make sure you’re maximizing your coverage benefits. 

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