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Over-21 Medicaid Diagnostic Services

The Issue
Under the existing system, Medicaid patients often receive unnecessary duplicative services and visit two practitioners (family physician and/or ear, nose, and throat physician) prior to receiving audiologic services, increasing the time to treatment and financial burden to the patient population and creating inefficiencies within the Medicaid system. Patients with hearing disorders can be effectively managed by an audiologist with hearing devices, counseling, and/or auditory system retraining utilization.

While global medical care for patients in the United States of America is historically some of the best in the world, audiologic care is out of reach for adult Medicaid patients in Kentucky.  An immediate step that should be taken to improve access to high-quality care for Kentucky patients over the age of 21, and thus improving their chances of escaping poverty, is to allow coverage of appropriate and necessary diagnostic audiology services.  This recommendation is consistent with recent recommendations from the National Academies of Sciences, Engineering, and Medicine, which state, “State Medicaid agencies should evaluate options for providing coverage for treating hearing loss (e.g., assessment, services, and hearing aids and hearing assistive technologies as needed) for adult beneficiaries.”

KAA’s Stance
Approving direct audiologic coverage for adults will minimize expenses to the Medicaid system by eliminating unnecessary or redundant medical appointments and allowing the patient to see an audiologist to manage hearing and balance-related concerns.  This population is currently underserved by a lack of access to audiologic care and will benefit greatly from the services that audiologists can offer.

Kentucky audiologists are already qualified by education, training, and authorized by state licensure to provide audiologic diagnostic and treatment services to Kentucky patients without physician supervision. Services requiring medical intervention are appropriately referred to a medical doctor or specialist, (i.e., otolaryngologist or neurotologic specialist) as is consistent with evidence-based guidelines and protocols.  Research definitively demonstrates that audiologists appropriately refer for medical treatment when necessary. It is also important to note that professional liability insurance is, on average, lower in cost for audiologists than any other clinical doctoring provider class, which is a testament to the safety and quality of the care that audiologists provide.
The Kentucky Academy of Audiology (KAA) and its member audiologists seek Medicaid policy improvements that will align existing requirements with contemporary evidence-based clinical practice, and markedly enhance the provision of audiologic services to adult Medicaid patients.

Where We Are Now
In September 2018, KAA met with the Physician TAC committee (which makes recommendations to the Department of Medicaid Services, or DMS) and made our case why diagnostic coverage for patients with Medicaid over age 21 years is necessary.  There was a unanimous decision to move this recommendation forward to the MAC (another committee that advises DMS about medical and health services) which was presented in November 2018.  The recommendation was submitted to DMS and unfortunately, their decision was not in our favor.  

The formal recommendation to DMS read:  
 The physician TAC recommends approving direct audiologic coverage for diagnostic services over the age of 21 years for audiologists under their specific NPI number, rather than having to be referred by an ENT or physician or billed incident to the physician, as in some managed care plans. This will eliminate expenses to the Medicaid system by eliminating unnecessary or redundant medical appointments and will allow better access to care in this under-served population.  Better access equals decrease in falls risks as well as decrease in psychosocial effects of hearing loss and dizziness, which is linked to higher rates of medical intervention.  

DMS response read:
 The KY Department of Medicaid Services Fee for Service Audiology program is distinctly applied to individuals age 21 and younger. Historically, audiology benefits have not been provided for individuals over age 21. A physician's referral is required to an audiologist for individuals age 21 years and younger.  

The department's focus is to ensure that an individual seeks care from a participating physician provider first to rule out any medical condition for a reported hearing loss.  If it is determined to be a functional loss of hearing that can be improved via hearing devices, the individual is referred to an audiologist for testing to determine if their hearing can be improved via hearing devices. 

Individuals over age 21 have coverage for services with a participating ENT physician.  At this time, audiology services are not available to this population.  

OUR ASK: We need support from family physicians, ENTs, NPs, psychologists, geriatric doctors, whomever, to help pass this adjustment in payer policy. We are encouraging any provider group to write letters of support in our favor to DMS. You can find draft a draft “ask” for providers, and a draft letter for providers who agree to sign on, in the links below.

Resources