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 entirely on your state's specific 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 dramatically by state. Currently, 26 states plus DC provide coverage without age restrictions (though limits may apply), while 8 states provide no adult coverage at all. You must confirm your state's policy.
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. While federal law guarantees coverage for children, 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 is 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 highlights why you must call your state's Medicaid office or Managed Care Plan to verify the exact rules for your age and condition.
Important: Coverage Can Change
Medicaid coverage for adults has expanded in several states recently (e.g., Washington, South Carolina). 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 the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program.
Why EPSDT is Critical
EPSDT requires Medicaid to cover any medically necessary service for children to correct or ameliorate defects, physical and mental illnesses, and conditions. This includes hearing devices, auditory training, and follow-up care when necessary for a child's 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 (due to growth, damage, or changing needs), not just every "X" years.
- 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). Finding care and getting devices involves understanding your plan's specific rules for prior authorization.
How to Access Care in an MCP
Follow these steps to ensure smooth access to hearing care:
Step 1: Confirm Eligibility & Network
Verify your enrollment and network requirements
- Verify active enrollment and know your Managed Care Plan (MCP) name.
- Call member services to verify hearing device coverage for your age group and any dollar limits that may apply.
- Find in-network providers: Use your MCP's provider directory to locate audiologists and ENTs (otolaryngologists) who accept your specific plan.
Step 2: Get Medical Evaluation
Obtain required assessments and recommendation
- See your PCP: Get a referral to an audiologist and/or ENT if required by your MCP.
- Complete the hearing test: Obtain a full audiological evaluation to document the degree and type of hearing loss.
- Get Recommendation: Your audiologist writes a strong letter recommending the specific hearing device (or cochlear implant) that is medically necessary.
Step 3: Prior Authorization
Your provider submits the Treatment Authorization Request (TAR)
Your provider (audiologist or ENT) will submit a Treatment Authorization Request (TAR) to your MCP or the state Medicaid agency. They must include the medical documentation (audiogram, ENT report, recommendation) to prove the device is necessary.
- Processing Time: Typically 14–30 days for routine requests.
- Follow-Up: Call your provider's office one week after your visit to ensure the TAR has been submitted.
Appeals Process: Challenging a Denial
If your device request is denied, you have the right to appeal. The process has two levels:
Level 1: MCP Internal Appeal
File with your Managed Care Plan first
You must typically file this appeal within 60 days of the denial notice. Call your MCP member services to initiate the appeal. Provide additional information or clarification that the original request lacked.
Level 2: State Fair Hearing
Appeal to the state Medicaid agency
If the MCP denies your internal appeal, you can request a State Fair Hearing. This is a formal appeal to an impartial hearing officer from the state Medicaid office. This is your strongest opportunity to argue medical necessity, especially for children under the EPSDT mandate.
Free Help: Organizations like Disability Rights California or your state's Protection & Advocacy (P&A) program can provide free legal representation for Medicaid appeals.
The Bottom Line
Medicaid and Medi-Cal can be powerful tools for accessing hearing aids, cochlear implants, and related services—but only if you understand how your state’s rules work. Children under 21 have strong protection through EPSDT, while adults face more variation and limits that depend on where they live.
The most important steps are to confirm your specific benefits, get clear medical documentation of need, and be prepared to appeal if a request is denied. You’re not asking for a luxury—you’re asking for medically necessary access to communication, safety, work, and school.
Next Steps
Use these tools and resources to understand your coverage, prepare for appointments, and get help if Medicaid or Medi-Cal denies hearing device benefits.