Mysterious "covered amount" by insurance company for hearing aids.

I wear hearing aids. My insurance (a retiree plan) just started to provide coverage for hearing aids, describing the coverage as “100% of the covered amount.” Yay!!

Can they tell me what the covered amount is so I can buy a new set? No.

Will they tell my audiologist what the covered amount will be? No.

Will they pay me in advance for them so I can go out and pick which ones I want? No.

What if I pick some, pay $4000 (not unusual) for them and only get reimbursed for half? May happen.

What if I pick a very basic pair, but I could have purchased much better ones and still have been covered? Too bad.

So, my audiologist has sent them an invoice for the most expensive pair they can order. She tells me that, in three or four weeks, I will either get a refusal, a request for more information, or a check from my insurance provider. Mind you, I haven’t ordered any new ones at all…she’s just submitting an invoice. “If you get a check, come in and we’ll see what we can do for you for that amount.”

I’ve spent several weeks working on this without success, so I have to admit that her solution appeals to me, but the situation is nuts.

In January, 2017, I was prescribed an apparatus to keep my left foot level while walking. Thankfully I still had employer paid insurance then. The guy at SportsMed who fitted the orthotic explained the procedure regarding payment.

“The full cost is $1136. Your co-pay is $248. We’ll file the claim with BC/BS, and whatever they pay, you’ll be responsible for the rest. Sign here to approve.”

Thankfully I only had to supply the co-pay for this basically 100 grams of carbon composite and some Velcro attachment belts. I also only wore it two weeks while my physical therapist helped me retrain my left leg to walk.

Mumble-grumble. You know, when I go to an auto mechanic with a problem, I don’t allow any work to be done without an “all-in total cost guaranteed price” for the work to be done. If anything comes up more than that, my mechanic knows there’ll be more negotiation and a new price guarantee before additional work. Try to get that in any usual kind of medical or pharmaceutical context. (Yes, I understand that there are some hospitals, surgery centers, and medication providers who do things just this way; there ought to be a lot more of them. For example:

Isn’t it insurance fraud to submit a claim before services are rendered? It seems backwards, at least. If your plan says 100% doesn’t that mean 100% no matter the cost?

But look at the weasel words from the insurance company, in the first paragraph of the OP! They say that they will cover 100% of the amount that they will cover. There is an amount they won’t cover. And they won’t explain what amount that is.

The real issue is that this type (or any type) of weasel words should be illegal in insurance policies. But for now, today, what can a person do to get an honest answer?

At least my dentist seems sort-of honest. His deal is, “Pay $200 per year, you get two cleanings and a set of X-rays with evaluation and discussion, and anything that comes up on top of that we’ll talk about.”

I was there in April, and when I was filling out intake forms, at the place it asked about “insurance provider”, I asked what I should put there. The receptionist said, “Leave it blank, we’re your insurance provider.”

What in the world could be simpler than that?

I’m also 66 (and therefore of Medicare age). My Medicare Part B premium is supposedly set at about $140 per month. However, it has been explained to me that, since I made “too much money” in 2016, my premium would be $450 per month. And I remember the Medicare debates from 1965, the vote, and how people talked about how medical care wasn’t going to cost them “anything”. I also remember, when I was age 13, thinking, “You people are morons, or criminals, or both.”

Why don’t you see what it would cost, cash, to buy something equivalent somewhere like Costco, where there is transparent pricing to begin with? They are pretty well-rated. Check the satisfaction guarantee.

“So, how does my coverage work?”

“Your plan pays 100% of reasonable and customary charges.”

“Who decides what’s reasonable and customary?”

“We do.”

“Okay, can you tell me what’s reasonable and customary in this case?”


“Who can?”


“Well, that certainly seems reasonable.”

“And customary.”

Yes, I’d be worried about this.

I once had dental coverage. The dentist I went to explained that what I needed wasn’t covered, but he could submit paperwork claiming to have done work that was covered. I went elsewhere.

It turned out that he also submitted claims for people who had no work done, then split the $$ 50/50 with them. He got caught.

Maybe, but the medicos and hospitals are pros at playing the games the insurance companies force them into.

I had a huge run around followed by a HUGE bill when I had jaw surgery done and had to go out-of-network. I called my insurance up several times before scheduling the surgery. We both knew how much the surgeon was charging, I was assured that after I hit my out of pocket max, they would cover, as I had gotten a waiver to do this. They DID warn about balance billing, but the surgeon’s assistant told me since it was approved and covered, no biggie.

After the surgery, when the thousand+ bill came in, the insurance company finally admitted that they covered 100% of what they allow their surgeons to charge for the procedure, even though they knew it was much less than what I was being charged. I didn’t know enough to specifically about that, if they would have revealed it beforehand.

Lots of medical/pharmaceutical places don’t tell you the price- but this one did. It’s $1136. And you’re responsible for them receiving full payment regardless of how much they do or don’t receive from the insurance company. When I go to the mechanic, they give me a price of $1136 and I don’t expect them to be able to tell me if my collision/comprehensive insurance will cover it or how much the insurance will pay.

I’m obviously a bit concerned with the idea that my audiologist will submit an invoice when I haven’t yet purchased any hearing aids, but it was their suggestion to do so and I figure that they are the “experts.”

OTOH, it wasn’t ME who submitted an invoice, so I think I’m in the clear as far as that goes.

Delivery is usually 4 to 6 weeks, so it’s not like the hearing aids will show up before I hear (no pun) from the insurance company.

And it’s not THAT unusual to pre-bill. In fact, I know quite a few suppliers who require some form of pre-payment (usually 50%) before manufacturing or shipping the product. Heck, my dentist requires it for a crown.

Finally, there is the usual statutory requirement for a “return for full refund within X days” that applies specifically to hearing aids. I can always reverse everything.

But…why the hell do I have to do this at all? Can’t my insurance company just say, “We’ll cover up to $2500?”

And, yeah, Costco has some good deals on units. But that still leaves me having to decide if I want to purchase $2000 units or $4000 units without knowing (at all) how much I will get reimbursed. I would literally have to buy a pair without knowing how much they will cost me out of pocket. Could be nothing, $1000, or $2500…who knows?

Years ago, insurance was BC/BS, but thru corporate parent in another state. Wanted to have a sleep study done. This would be overnight in a hospital. If it was considered inpatient (on the argument that I was spending the night) it would be relatively inexpensive, just a few hundred dollars. If it was considered outpatient (on the argument that it didn’t need to happen in a hospital & that they were effectively a clinic) it would cost me thousands of dollars, at least $6000 as I remember.

NO one could tell me how much it would cost until after I had the study done. BC/BS - corporate state couldn’t tell me because it wasn’t happening in their state. BC/BS local couldn’t tell me because they weren’t doing the billing. All the Sleep Center could tell me is the rack rate. Ultimately, never had it done because I wasn’t willing to gamble that it would be affordable.