If you or your child relies on Medicaid (known as Medi-Cal in California), navigating coverage for hearing aids, cochlear implants, and related services can be confusing. Coverage varies significantly across the country and often differs dramatically between children and adults.
This guide breaks down your rights and benefits. The most important takeaway: children under 21 are covered in all states for all medically necessary hearing services. For adults, coverage depends on your state’s rules.
The bottom line on Medicaid coverage
Children under 21: Medicaid provides comprehensive coverage for hearing devices through the federal EPSDT mandate with no dollar caps or arbitrary frequency limits, regardless of the state you live in.
Adults: Coverage varies by state. This article states that 26 states plus DC provide coverage without age restrictions (though limits may apply), while some states provide no adult coverage at all.
California (Medi-Cal) specifics: Adults have a cap of $1,510 per calendar year for hearing aids, while children receive unlimited coverage through EPSDT and specialized programs like CCS.
State-by-state adult coverage overview
Medicaid hearing device coverage is not standardized across states. Federal law guarantees coverage for children, but adult coverage is an optional benefit chosen by each state.
| Coverage level | States (examples) | What’s typically covered for adults |
|---|---|---|
| Full coverage (26 states + DC) | CA, NY, MA, WA, MI, NJ, VT, etc. | Hearing aids, evaluations, and accessories are covered, often with limits (e.g., dollar caps or frequency limits). |
| Restricted coverage (16 states) | IL, PA, TX (children only), FL (children only), etc. | Coverage is limited: may cover only testing/repair, pregnant women only, or limited to specific settings. |
| No adult coverage (8 states) | AL, GA, ID, LA, MO, OK, SD, WY | Only children under 21 receive hearing device coverage. |
Coverage examples: California (Medi-Cal)
- Adults: $1,510 per calendar year cap (covers evaluation, fitting, devices, accessories)
- Children: Unlimited coverage through EPSDT and California Children’s Services (CCS)
- Replacements: Every 5 years if medically necessary; loss/theft not covered for adults
This variability is why you must call your state Medicaid office or Managed Care Plan to verify the rules for your age and condition.
Important: coverage can change
Adult Medicaid hearing benefits can expand or contract. Always verify current benefits directly with your state Medicaid agency before assuming coverage is unavailable.
Children’s coverage: the EPSDT mandate
If your child is under 21 and enrolled in Medicaid, federal law mandates comprehensive coverage for hearing devices and services through EPSDT (Early and Periodic Screening, Diagnostic, and Treatment).
Why EPSDT is critical
EPSDT requires Medicaid to cover any medically necessary service for children to correct or ameliorate conditions. This includes hearing devices, follow-up care, and related services needed for development, education, and health.
Key benefits under EPSDT
Under EPSDT, Medicaid cannot impose arbitrary limits on children’s hearing care that it might apply to adults. This means:
- No dollar caps: Coverage is based on medical necessity, not a maximum dollar amount.
- No arbitrary frequency limits: Devices can be replaced as medically necessary (growth, damage, changing needs).
- Comprehensive accessories: Batteries, remote microphones, and essential assistive listening devices must be covered.
- Related services: Auditory-verbal therapy and necessary speech/language services are also covered.
| Coverage feature | Children under 21 (EPSDT) | Adults (state-dependent) |
|---|---|---|
| Dollar caps | None — coverage based on medical necessity | Varies by state (e.g., CA $1,510/year limit) |
| Replacement frequency | As medically necessary (growth, damage, changing needs) | Typically every 3–5 years |
| Cochlear implants | Covered when medically necessary | Covered in most states when criteria met |
Accessing care: MCPs, authorization, and appeals
Most Medicaid recipients are enrolled in Managed Care Plans (MCPs). Getting devices often involves network rules and prior authorization.
How to access care in an MCP
Use these steps to improve the odds of a smooth process:
Step 1: Confirm eligibility & network
Verify your enrollment and your plan’s requirements
- Verify active enrollment and identify your Managed Care Plan (MCP).
- Call member services to verify hearing device coverage for your age group and any dollar limits.
- Find in-network providers: Use the plan directory to locate audiologists and ENTs who accept your plan.
Step 2: Get medical evaluation
Obtain required assessments and documentation
- See your PCP for referrals if required by your plan.
- Complete the hearing test to document degree and type of loss.
- Get a recommendation: Your audiologist documents why the specific device (or implant) is medically necessary.
Step 3: Prior authorization
Your provider submits the authorization request
Your provider submits a request (often called a TAR in Medi-Cal) with supporting documentation (audiogram, ENT report, justification) to prove medical necessity.
- Processing time: Often 14–30 days for routine requests.
- Follow-up: Check with the provider’s office about a week after your visit to confirm submission status.
Appeals process: challenging a denial
If your request is denied, you have the right to appeal. Your process may vary by state, but often includes two levels:
Level 1: MCP internal appeal
File with your Managed Care Plan first
You may need to file within 60 days of the denial notice. Call member services to initiate the appeal and submit clarifying documentation.
Level 2: State fair hearing
Appeal to the state Medicaid agency
If the plan denies your internal appeal, you can request a State Fair Hearing. This can be particularly powerful for children under EPSDT protections.
Free help: Protection & Advocacy (P&A) organizations (for example, Disability Rights programs) may provide free legal assistance for Medicaid appeals.
The bottom line
Medicaid and Medi-Cal can be powerful tools for accessing hearing aids, cochlear implants, and related services—especially for children under EPSDT.
For adults, benefits vary by state. Confirm your plan’s rules, document medical necessity clearly, and appeal denials. Access to communication, safety, work, and school is the point.