Assuring Access to Hearing Aids for Infants and Young Children with Hearing Loss Karl R. White National Center for Hearing Assessment and Management Peggy McManus Maternal and Child Health Policy Research Center Irene Forsman Maternal 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 (Hearing aid exam, binaural): $62.84 (range $ $165): change (4% decrease since 2000) (Electroacoustic evaluation):$49.03 (range $ $200); change (35% decrease since 2000) V5140 (Hearing aid binaural, BTE): $ (range $400 - $960.68); change (2.8% increase since 2000) (Visual reinforcement audiometry): $19.66 (range $ $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 Ages Newborn1-12 mos13-24 mos25-36 mosTotal Prevalence 3 per 1, per 1,000 Number of infants and young children with bilateral hearing loss needing Has (Number of hearing aids required) 9,600 (19,200) 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) 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) 23,760 (44,880) Total cost $3,000/aid) $61.2 million $24.48 million $ 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