EHDI Services: Who Pays for What? Services provided through early hearing detection and intervention (EHDI) programs, located in all states and the District of Columbia, are funded through a variety of public and private sources, and navigating the maze can be confusing for families. Audiologists and speech-language pathologists who understand these resources are an asset to ... Bottom Line
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Bottom Line  |   September 01, 2011
EHDI Services: Who Pays for What?
Author Notes
  • Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.
    Janet McCarty, MEd, CCC-SLP, private health plans advisor, can be reached at jmccarty@asha.org.×
  • Paul Farrell, AuD, CCC-A, associate director of audiology professional practice, can be reached at pfarrell@asha.org.
    Paul Farrell, AuD, CCC-A, associate director of audiology professional practice, can be reached at pfarrell@asha.org.×
  • Anne Oyler, MA, CCC-A, associate director of audiology professional practice, can be reached at aoyler@asha.org.
    Anne Oyler, MA, CCC-A, associate director of audiology professional practice, can be reached at aoyler@asha.org.×
Article Information
Hearing Disorders / Special Populations / Early Identification & Intervention / Bottom Line
Bottom Line   |   September 01, 2011
EHDI Services: Who Pays for What?
The ASHA Leader, September 2011, Vol. 16, 3-37. doi:10.1044/leader.BML1.16112011.3
The ASHA Leader, September 2011, Vol. 16, 3-37. doi:10.1044/leader.BML1.16112011.3
Services provided through early hearing detection and intervention (EHDI) programs, located in all states and the District of Columbia, are funded through a variety of public and private sources, and navigating the maze can be confusing for families. Audiologists and speech-language pathologists who understand these resources are an asset to families.
EHDI programs screen newborns for hearing loss prior to hospital discharge and provide follow-up diagnostic evaluation. Those identified with hearing loss are enrolled in early intervention programs designed to help them develop communication skills. State EHDI program coordinators work with providers and programs to ensure these goals are met through an assortment of resources, programs, and funding mechanisms available to help children with hearing loss and their families. A review of services and programs available for children with hearing loss follows.
Early Detection Importance
The number of infants born with permanent hearing loss—approximately three in 1,000—makes the condition one of the most common birth defects in America. Infants identified with hearing loss can be fitted with amplification at as young as 4 weeks of age; with appropriate early intervention, children with hearing loss can succeed in regular elementary and secondary education classrooms.
Children born with a hearing loss who are identified and given appropriate intervention before 6 months of age demonstrate significantly better speech and reading comprehension than children identified after 6 months of age. The most critical time for stimulating the hearing centers in the brain is during the first few months of life. Late identification of hearing loss or lack of early intervention services can negatively affect speech and language development, academic achievement, and social-emotional development. Knowing how and what services to access at appropriate times is crucial for the best outcomes.
IDEA Part C and Early Intervention Programs
The Early Intervention Program for Infants and Toddlers With Disabilities, also known as Part C of the Individuals With Disabilities Education Act (IDEA–Part C), provides grants to states to assist and maintain a statewide system of coordinated, comprehensive, and interagency programs of early intervention (EI) services for children from birth through age 2 and their families. EI services bring together families and service providers from many parts of the community, including public and private agencies, parent-child centers, local school districts, and private providers. Payment for services may come from a variety of sources, including private insurance, Medicaid, participating agencies, local schools, and family cost-sharing. Services include assistive technology, audiology, speech-language pathology, occupational and physical therapy, vision, nutrition, and other services. Part C services may be administered, for example, by a state’s department of public health or department of education. State EHDI programs may offer the link between medical center services and Part C early intervention services. North Carolina offers an example of successful partnerships among EHDI-related agencies within a state.
At age 3, a child with hearing loss is transitioned from Part C early intervention services to the local school system through IDEA Part B, which provides a free and appropriate education to a child with a disability, including a child with hearing loss.
Medicaid
As the largest single insurer of children in the United States, Medicaid is one of the major sources of funding for hearing services. Medicaid is funded by both the federal and state governments, with each state administering its own program and establishing eligibility requirements. One of the primary mechanisms by which Medicaid services are provided to children is the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. EPSDT services focus on the prevention and early treatment of children’s health problems, and states are required to cover a comprehensive set of services, including speech- language pathology and audiology. EPSDT may fund EI services and hearing aids. All services must be medically necessary. Each state may have its own unique name for its EPSDT program—for example, in Ohio the program is named “HealthCheck,” and Louisiana’s program goes by “KIDMED.”
IDEA and EPSDT funds are available for EI services, although for different purposes. EPSDT serves low-income children; IDEA serves children regardless of income. Services provided under an IDEA Individualized Family Service Plan (IFSP) can be covered by Medicaid if the child qualifies. IDEA Part C is the payer of last resort.
The Centers for Medicare and Medicaid (CMS) administers the State Children’s Health Insurance Program, now known as the Children’s Health Insurance Program (CHIP), which was designed to provide insurance coverage for children of families earning too much to qualify for Medicaid but too little to afford private coverage. CHIP is financed by the federal and state governments and is administered by the states. Within broad federal guidelines, each state determines program design, eligibility, benefit packages, payment levels for coverage, and administrative and operating procedures, much like Medicaid. States may vary eligibility rules, but in most states, uninsured children younger than 19 whose families earn up to $36,200 a year (for a family of four) are eligible.
Hearing Aid Coverage for Children
Private health plans may include hearing aids in their benefits. Eighteen states mandate hearing aid coverage for children, and some mandate coverage for adults as well. These legislative successes are the result of collaborative efforts by consumer organizations and state speech-language-hearing associations. The impetus for these mandates comes in part from EHDI laws, which call for universal newborn hearing screening and follow-up intervention services when hearing loss is detected.
The typical mandate calls for hearing aids for those 18 years and younger. The mandates usually include dollar limits; Kentucky law, for example, requires coverage for one hearing aid per ear (up to $1,400) every 36 months. New Jersey coverage includes $1,000 per hearing aid for each ear every 24 months, and Oregon allows a maximum benefit of $4,000 every 48 months.
Private Health Plans
Private health plans also may be a payment source for audiology and speech-language pathology services for a child with a hearing loss. However, health plans may exclude congenital conditions or services rendered in the public school. Careful review of the plan will determine coverage of services related to a child’s hearing loss.
Health care reform may improve coverage of services for children with hearing loss. The Patient Protection and Affordable Care Act calls for an “essential benefits” package that includes habilitative and rehabilitative services. ASHA continues to work diligently to make sure such comprehensive services are part of health care reform efforts.
Cochlear Implants
IDEA Part C services include assistive technology devices, such as assistive listening devices, hearing aids, personal FM units, and closed captioning. Part C does not cover a medical device that is surgically implanted, or the replacement of such a device. Cochlear implants (CIs) are in this category and, therefore, not covered under IDEA Part C.
Medicaid coverage and payment for CIs and related services may differ from state to state, but generally, under the EPSDT program, services related to prosthetic devices and durable medical equipment for children are covered.
Private health plans vary for coverage of CIs. Cigna, for example, covers children (age 12 months to 17 years, 11 months) who have profound, bilateral sensorineural hearing loss with thresholds of 90 dB or greater at 1000 Hz, and limited or no benefit from a three-month trial of appropriately fitted binaural hearing aids.
GAO Report
To understand more fully how federal programs support children who are deaf and hard of hearing, the Government Accountability Office (GAO) examined the settings in which these children are educated, factors that help children who are deaf and hard of hearing acquire language and literacy skills, and the challenges to providing appropriate interventions for these children (GAO-11-357, May 25). According to the study report, children who are deaf and hard of hearing are educated in a variety of settings, from regular classrooms to separate schools for the deaf. Data from the U.S. Department of Education indicate that the majority of these children who receive special education did so in regular early childhood programs or regular classrooms for at least part of their day.
Experts interviewed by GAO noted several key factors for ensuring that children with hearing loss acquire language and literacy skills; early exposure to language (either spoken or signed) is a critical element because children learn a language most easily during the first few years of life. The experts noted that limited information and resources are challenges to providing appropriate interventions to children with hearing loss, and that parents may not always understand the importance of enrolling their children in early intervention services.
Link to Pediatric Audiology Services
A national web-based directory designed to help families identify appropriate pediatric audiology facilities is under development (see The ASHA Leader, May 17, 2011). The EHDI Pediatric Audiology Links to Services (PALS) Directory includes information on facilities that employ licensed audiologists and have the appropriate equipment to carry out pediatric services. The directory will be available in early 2012.
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September 2011
Volume 16, Issue 11