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