Background <p>Age-related hearing loss (HL) is highly prevalent, undertreated, and can negatively impact quality of life. Music engagement, which supports cognition and well-being, is affected by HL; however, implications of HL on music reward remain unclear. The authors hypothesized that worsening HL may reduce music perception and engagement, but reward may be preserved through musical training and impaired by increasing age.</p> Methods <p>The present study used a convergent mixed-methods approach to examine the cross-sectional associations between HL and music perception, engagement, and reward, and to contextualize these findings through qualitative inquiry. Eighty-five older adults aged 60 years or above participated across the hearing spectrum, defined by pure tone audiometry of the better hearing ear (PTAB) for non-implanted individuals (normal hearing, unaided HL, hearing aid users) and speech recognition scores for cochlear implant (CI) individuals. Quantitative analyses were restricted to non-implanted participants (<i>N</i> = 80); CI users (<i>N</i> = 5) were excluded due to their distinct auditory and perceptual profiles. Quantitative measures included validated cross-sectional outcomes such as the Goldsmiths Musical Sophistication Index (GMSI) and Barcelona Music Reward Questionnaire (BMRQ) focused on musical training, perception, engagement, and reward, and were analyzed using multivariate linear regression. A purposive subset (<i>N</i> = 18) including CI users completed qualitative interviews analyzed using an abductive approach. Quantitative and qualitative findings were integrated to generate overarching meta-inferences.</p> Results <p>Worsening HL severity was associated with reduced music perception and listening frequency, but not with active music participation nor overall music reward. However, greater musical training predicted improved music perception, engagement, listening frequency, and reward. Increased age had a small, albeit non-significant, effect on music engagement and reward. Qualitative interviews echoed these findings—despite perceptual challenges constraining engagement, music remained enjoyable for most participants, primarily through emotion evocation (e.g., nostalgia).</p> Conclusions <p>Although greater age-related HL was associated with reduced music perception and engagement, music reward may be preserved through factors like musical training and adaptive strategies, underscoring the importance of personalized counseling and music-based aural rehabilitation.</p>