Post on 25-Dec-2015
Assuring Access to Hearing Aids for Infants and Young Children with Hearing Loss
Karl R. WhiteNational Center for Hearing Assessment and Management
Peggy McManusMaternal and Child Health Policy Research Center
Irene ForsmanMaternal and Child Health Bureau
Prevalence and Consequences of Hearing Loss
2-3 per 1,000 newborns are DHH; additional 6-7 per 1,000 by 5 years of age
Early onset hearing loss often requires hearing aid features only available in digital aids
If amplified and treated properly many children with DHH will require few, if any, special education services after age 5
Barriers to Accessing Hearing Aids for Infants and Young Children Who Are DHH
High loss to follow-up rates
Shortage of pediatric audiologists
Inadequate financial resources for purchasing hearing aids (private or public)
Potential Sources of Funding
Medicaid and SCHIP
Private Insurance
Part C of IDEA
Hearing Loaner Programs
Medicaid and SCHIP More than 50% of children are covered by Medicaid
and/or SCHIP EPSDT is required part of Medicaid that provides
preventive health care (and where needed) treatment services to children
All Medicaid and most SCHIP programs cover hearing aids and related services, BUT:
Reimbursement rates are very low
Medical necessity restrictions often result in inappropriate aids being fit
Difficulty with timely authorization and reimbursement contributes to low participation rates and delays in needed services to families
Assessing Current Practices
15 state survey, conducted by MCH Policy Research Center, January – March 2005
Examined Fee for Service (FFS) policies for a comprehensive set of hearing services
Obtained 2005 fees and compared them to 2000 fees collected by MCHPRC in previous study
Selected Hearing Aid Services
Medicaid fees are low relative to Medicare and commercial fees– only 67% of Medicare fees and 38% of commercial fees; and getting worse 92591 (Hearing aid exam, binaural): $62.84 (range
$36.24 -$165): change (4% decrease since 2000)
92595 (Electroacoustic evaluation):$49.03 (range $8.71 - $200); change (35% decrease since 2000)
V5140 (Hearing aid binaural, BTE): $775.89 (range $400 - $960.68); change (2.8% increase since 2000)
92579 (Visual reinforcement audiometry): $19.66 (range $4.50 - $28.60); (5% decrease since 2000)
Private Health Insurance
Less than 40% of infants and young children covered by private health insurance
Only 7-16% of private health insurance policies provide any coverage for hearing aids
In addition to pervasive lack of coverage, relying on private insurance is difficult because:
Employers often don’t understand the importance of hearing loss for young children
Hearing aid riders seldom taken by employers
Mandated benefits do not cover most of cost
Use of ‘not in network’ providers results in higher costs to families
Part C of IDEA
Wide variation in eligibility requirements among states
Part C statute and rules are silent on whether hearing aids considered an Assistive Technology
Limited funding
Hearing Aid Loaner Programs
28 states have some type of hearing aid loaner program operated by wide variety entities
In 2005, programs in 6 states (AZ, IN, OH, OR, PA, TX) accounted for 70% of loans
Most programs report Lack of funding to purchase, maintain, and repair
Many depend on recycled aids with older technology
Lack of awareness among users of availability
Annual Number and Cost of Hearing Aids Needed by 0-3 year olds in the US
28 states have some type of hearing aid loaner program operated by wide variety entities
In 2005, programs in 6 states (AZ, IN, OH, OR, PA, TX) accounted for 70% of loans
Most programs report Lack of funding to purchase, maintain, and repair
Many depend on recycled aids with older technology
Lack of awareness among users of availability
Number and Cost of Hearing Aids
AgesNewborn 1-12 mos 13-24 mos 25-36 mos Total
Prevalence 3 per 1,000 1.2 per 1,000 1.2 per 1,000 1.2 per 1,000Number of infants and young children with bilateral hearing loss needing Has (Number of hearing aids required)
9,600 (19,200)
3,840 (7,680)
3,840 (7,680)
3,840 (7,680)
21,120 (42,240)
Number of infants and young children with unilateral loss needing HAs (Number of hearing aids required)
1,200 (1,200)
480 (480)
480 (480)
480 (480)
2,640 (2,640)
Total children with unilateral and bilateral hearing loss needing HAs (Number of hearing aids required)
10,800 (20,400)
4,320 (8,160)
4,320 (8,160)
4,320 (8,160)
23,760 (44,880)
Total cost (@ $3,000/aid) $61.2 million
$24.48 million
$24.48 million
$24.48 million
$134.64 million
Option #1: Expand eligibility of DHH children and coverage of hearing aids by Part C
Clarify that all children with permanent hearing loss are eligible for Part C services
Clarify that the definition of ‘assistive technology” which is a required service, includes hearing aids
To dramatically reduce costs, enable Part C programs to participate in national hearing aid purchasing contracts managed by the Department of Veterans Affairs
Option #1 (Part C): Pros and Cons
Pros: All DHH children would have access to hearing aids and related
services
Reduce costs of later special education services
As “payor of last resort,” Part C can draw down private and public money
Part C’s nationwide network would enable participation in the VA purchasing contracts that would result in huge savings (90%+) to families and taxpayers.
Cons: Requires additional funding for Part C
Not clear that Part C is eligible to participate in VA contracts (may require Congressional action)
Option #2: Improve coverage of hearing aids for DHH children by Medicaid and SCHIP
Clarify that digital aids with appropriate features (not analog aids) are the “medically necessary” device for 0-3 year old DHH children
Increase reimbursement rates for digital aids and related services
Improve timeliness of approving and paying for digital hearing aids for infants and young children
Option #2 (Medicaid): Pros and Cons
Pros: >50% of all infants and young DHH children already covered by
Medicaid
Medicaid already mandates coverage of hearing aids and related services through EPSDT
Cons: There is a long history of failure to implement EPSDT
States establish their own “medical necessity” definitions and payment rates
In some states, SCHIP excludes coverage of hearing aids or imposes coverage limitations or cost-sharing
Option #3: Expand Private Insurance Coverage of Hearing Aids for 0-3 year-old DHH Children
Pass legislative mandates in every state (9 currently have mandates) to require coverage of digital hearing aids and related services
Increase coverage amounts to reasonable levels and frequency
Option #3 (Private Insurance): Pros and Cons
Pros: ~20% of children would benefit
Increase in premiums from adding a hearing aid mandate for children is likely less than 1%
Current commitments to national health insurance create opportunities
Cons: Because of ERISA (exemption for self-insured plans), many privately
insured children would not be covered
State legislatures are increasing reluctant to pass insurance mandates
Requires separate implementation in every state and will likely be opposed by insurers and employers
Option #4: Expand hearing aid loaner programs
Many potential partners and participants (e.g., Assistive Technology Act programs, Part C, Title V, EHDI program, children’s hospitals, LEND programs)
Would need to provide quick, short-term access to digital hearing aids
Option #4 (Loaner Programs: Pros and Cons
Pros: Would provide quick access while families wait for coverage
under Part C, Medicaid, or private health insurance
The legal authority to operate hearing aid loaner programs already exists under the Assistive Technology Act, Part C, EHDI, or Title V
Costs for a loaner program are relatively low
Cons: Requires new funding and an infrastructure to ensure quality
and broad coverage
Of very limited value unless it is done in conjunction with one or more of the other three