Hospitals Cover for implantation of hearing devices
Implantation of hearing devices during a hospital admission
The Australian government requires health funds to pay for implantation of hearing devices for silver and gold categories of hospital private health cover, as per the Private Health Insurance (Prostheses) Rules (No. 4) 2019.
Cover is usually to the amount set by the Federal government, who revise and publish the Prosthesis List three times per year. The list identifies items related to prosthesis and the amount that health funds must pay when their members meet eligibility criteria. Items on the Prosthesis list related to implantation of hearing devices requiring hospital admission have been extracted and are listed below. Most devices on the list may not attract a gap fee, and if so, then an alternative no-gaps device must also be listed.
Health funds have the option to offer cover for implantation of hearing devices as part of bronze or basic hospital schemes. As a result, individual differences between schemes and funds apply at the lower levels of cover.
In some cases waiting times (when first joining a scheme or changing schemes) and benefit cycles (eg being eligible only every 3 or 5 years) may apply.
Medical specialists and audiology clinics may charge for consultations and other services that may not be covered by the hospital cover, so out of pocket expenses my apply.
Private health funds may offer a scheme that pays for accommodation in a public hospital only. In such cases, cover for implantation of hearing devices is usually restricted. Medicare and your health fund benefit will typically be combined to pay the Medicare Schedule Fee for that treatment (ie, what Medicare alone would have paid had you gone public). As a private patient (in either a public or private hospital) your doctor may charge you fees that are for your own account - ie gap fees. Check with your fund, your audiologist and your surgeon as to what out of pocket expenses will apply in your case.
Replacement and Upgrade of Sound Processors (not requiring hospital admission)
Replacement of damaged processors or upgrading to new processors does not require hospitalization and so is not automatically covered by hospital cover, even for the highest levels of cover. Individual funds set their own rules regarding cover for replacement of sound processors and will typically make a decision on a case by case basis.
Please read the information for your individual fund and consult your fund to check eligibility before agreeing to a replacement or upgrade.
Repairs are not generally covered by hospital schemes. In some cases, those with Extras cover (in addition to hospital cover, in combined packages) may be eligible for small amounts towards repairs and maintenance of implanted hearing devices.
The Prosthesis List - Extraction of items associated with implantation of hearing devices
The table below shows Cochlear Implants, Speech Processors (Initial and Replacement where a hospital admission is required) and Bone Conduction Hearing Systems, as shown in the November 2022 Prosthesis List.
The full Prosthesis list is available from the Department of Health.
Check the summary of each fund to establish which level of cover provides for this benefit and for any additional rules that may apply to a particular fund.