The following message was e-mailed on January 31 to Kathleen Sebelius, U.S. Secretary of Health and Human Services (HHS). It is published here with the permission of the signatories.
PROMINENT ADVOCATES FOR PEOPLE WITH DISABILITIES ASK FOR GUARANTEED ACCESS TO HEARING AID COVERAGE NATIONWIDE
Dear Secretary Sebelius,
The undersigned organizations submit this response to the Essential Health Benefits (EHB) Bulletin, released by the Center for Consumer Information and Insurance Oversight (CCIIO) on December 16, 2011. We write to express our disappointment at the approach taken with respect to coverage of hearing aids and related services.
As you know, section 1302(b)(1)(G) of the Affordable Care Act (ACA) explicitly required that the Secretary define essential health benefits to include items and services in the category of rehabilitative and habilitative services and devices. Our comments on the proposed EHB Bulletin fall into three categories: (1) The Bulletin fails to provide coverage for rehabilitative devices, like hearing aids, despite the specific language of the law; (2) the Bulletin fails to comply with the ACA’s requirement that the Secretary take into consideration the needs of individuals with disabilities; and (3) the intended regulatory approach is insufficient to provide coverage for hearing aids due to its reliance on the existing marketplace, which fails to offer consistent coverage of hearing aids. Each of these issues is discussed in greater detail below.
HEARING LOSS BACKGROUND
Hearing loss is a significant problem for many Americans. Some 36 million American adults report some degree of hearing loss (with some estimates as high as 48 million adults). Approximately 2 to 3 out of every 1,000 children in the United States are born deaf or hard of hearing. In addition, the CDC has documented substantial economic costs for children who are deaf or hard of hearing.
For example, one CDC study showed that for a single school year, the cost in the United States for special education programs for children who were deaf or hard of hearing was $652 million, or $11,006 per child. Furthermore, the CDC estimates that the lifetime costs for all people with hearing loss who were born in 2000 will be $2.1 billion, consisting of direct medical costs, such as prescription drugs, doctors visits and hospital stays (6%); direct non-medical expenses, such as home modifications and special education (30%); and indirect costs, including the loss of wages when a person cannot work or is limited in the type of work he or she can perform (63%). Thus, in our view, the largest component of the cost associated with this population is one that can be directly impacted by access to hearing aids.
Properly fitted hearing aids and aural rehabilitation techniques can assist individuals with hearing loss in adapting to their surroundings and improving communication. Use of hearing aids and services can help individuals with hearing loss function in their communities and engage in a greater number and type of employment. For example, one study found a $14,100 income differential between individuals with mild and severe hearing loss and that people with untreated hearing loss lose as much as $30,000 a year, depending on the degree of impairment.1 Hearing aids were shown to mitigate income loss by 90%-100% for those with milder hearing loss and 65%-77% for those with severe to moderate hearing loss.1 Finally, the study showed a strong relationship between the degree of hearing loss and unemployment for unaided patients–those with severe hearing loss had unemployment rates of 15.6%, or double that of the population (7.8%).1
These findings indicate the importance of hearing aids in obtaining employment and the critical nature of a hearing aid benefit, particularly for the working population. Hearing aids also assist individuals with profound hearing loss by alerting them to environmental sounds (such as emergency vehicles). Finally, a new and growing body of research shows that untreated hearing loss in older adults is related to cognitive decline, social isolation, depression, and possibly even dementia.
All of these downstream effects have significant repercussions for the individuals’ health and the healthcare system. Despite these profound and diverse needs, research shows that approximately only 24.5% of people who could benefit from hearings aids receive them.
In addition, properly fitting hearing aids improve quality of life for individuals with hearing loss. Specifically, a June 2011 study of hearing aid technological developments found that 75% of patients studied reported that at least one area of their life was improved by wearing hearing aids.2
COVERAGE OF HABILITATIVE SERVICES
In general, the EHB Bulletin requires that the EHB be defined by a benchmark plan selected by each state. States are permitted to select a benchmark plan to serve as the standard for qualified health plans inside the Exchange operating in their state and plans offered in the individual and small group markets in their state.
In the EHB Bulletin, CCIIO sets out specific options for coverage of habilitative services. The EHB Bulletin describes that although there are varying definitions of habilitative services, the concept is “virtually unknown in commercial insurance.”3
The EHB Bulletin sets out two options for coverage in the event the benchmark plan does not cover habilitative services: (1) Habilitative services would be offered at parity with rehabilitative services–a plan covering services such as PT, OT, and ST for rehabilitation must also cover those services in similar scope, amount and duration for habilitation; or (2) as a transitional approach, plans would decide which habilitative services to cover and would report on that coverage to HHS. HHS would evaluate those decisions and further define habilitative services in the future.
Issue One: HHS’s proposed approach does not provide coverage of rehabilitative and habilitative devices, one of the categories required by the ACA
The undersigned organizations were disappointed to find that the EHB Bulletin makes no mention of coverage for rehabilitative and habilitative devices, like hearing aids. Although the ACA explicitly requires coverage of devices in this category, mention of such devices is absent from the EHB Bulletin.
In particular, the EHB Bulletin fails to directly address rehabilitative services or devices despite specific inclusion of this category in the ACA. This exclusion leaves coverage of these services solely to the discretion of state health insurance plans. Further, even where state plans provide coverage of rehabilitative services, such coverage is likely to be inconsistent or inadequate, providing no guarantee of access to hearing aids and services.
As described above, hearing aids are an essential component of healthcare coverage for millions of Americans. They are essential to employment opportunities and improving quality of life for individuals with hearing loss. In addition, the healthcare reform law explicitly contemplates these types of devices. We encourage the Department to revisit its guidance with respect to the category of rehabilitative and habilitative services and devices and explicitly require that the EHB package include coverage of properly fitted hearing aids.
Issue Two: HHS’s proposed methodology does not satisfy ACA’s requirements that the EHB package take into account the healthcare needs of people with disabilities
The ACA required that the Secretary take into account the healthcare needs of specific groups, including people with disabilities.4 However, the EHB Bulletin fails to make any specific consideration of these individuals. We believe that such an approach is inconsistent with the letter of the ACA, which was intended to provide specific consideration and coverage for individuals with disabilities. We encourage the Secretary to consider individuals with disabilities and, in particular, individuals with hearing loss, when revising this Bulletin.
Issue Three: HHS’s proposed methodology is insufficient to guarantee access to hearing aid coverage
We are concerned that the proposed state-by-state benchmarking methodology is insufficient to guarantee access to hearing aid coverage. Specifically, HHS acknowledges in the EHB Bulletin that, although existing plans on the market may cover hearing aids, coverage of hearing aids varies by state and by plan. Therefore, we are concerned that in many states, the benchmark plans selected may not include any access to rehabilitative devices, like hearing aids. The intent of the ACA was to provide coverage of items and services that were previously uncovered in the marketplace. Therefore, we believe that in order to accomplish the goals of the law, the Department should amend its approach to explicitly require coverage of properly fitted hearing aids in the EHB in each state.
We appreciate your consideration of these comments. We hope that revised guidance will ensure coverage of properly fitted hearing aids and rehabilitation services as part of the EHB package.
This letter was signed by the following leaders and their organizations:
Alexander T. Graham, Alexander Graham Bell Association for the Deaf and Hard of Hearing
Dennis Fitzgibbons, Alpha One
Tamara Bushnik, American Congress of Rehabilitation Medicine
Marty Exline, Association of Assistive Technology Act Programs
Brenda Estes, Association of Late-Deafened Adults
George Lyons Jr., American Speech-Language-Hearing Association
Laurie Hanin, Center for Hearing and Communication
Larry K Quinsland, Council of American Instructors of the Deaf
Janice Schacter, Hearing Access Program
Andrea Boidman, Hearing Health Foundation
Brenda Battat, Hearing Loss Association of America
Gary Arnold, Little People of America
Donald E. Clayback, National Coalition for Assistive and Rehab Technology
Geraldine Dietz Fox, National Organization For Hearing Research Foundation
Cheryl A. Heppner, Northern Virginia Resource Center for Deaf and Hard of Hearing Persons
Pennsylvania Council of the Blind
Janet L. Bailey, Registry of Interpreters of the Deaf
Nell Bailey, Rehabilitation Engineering and Assistive Technology Society of North America
Claude Stout, Telecommunications for the Deaf and Hard of Hearing, Inc.
1. Kochkin S: The efficacy of hearing aids in achieving compensation equity in the workplace. HearJ 2010;62(10):19-26.
2. Kochkin S: Patients report improved quality of life with hearing aid usage. HearJ 2011;63(6):25-32.
3. Department of Health and Human Services: EHB Bulletin, at 11.
4. ACA, § 1302(b)(4)(C).