Key Takeaways:

1. Direct Access for Patients: The legislation would reclassify audiologists as Medicare-recognized practitioners, allowing beneficiaries to access care without needing a physician referral.
2. Broad Bipartisan and Organizational Support: The bill is supported by both Democratic and Republican senators and endorsed by leading audiology, aging, and rural health organizations.
3. Focus on Equity and Efficiency: Advocates emphasize that modernizing outdated Medicare rules will reduce red tape, improve care access, and enhance health outcomes for millions affected by hearing loss.

U.S. Senators Elizabeth Warren (D-Mass.), Rand Paul (R-Ky.), and Chuck Grassley (R-Iowa) are reintroducing the bipartisan Medicare Audiology Access Improvement Act, legislation to ensure that seniors and people with disabilities on Medicare are able to access a full range of hearing and balance healthcare services provided by licensed audiologists.

Currently, audiologists are classified as non-physician healthcare professionals that are trained in the diagnosis, treatment, and rehabilitation of individuals with hearing, balance, and related disorders. Although Medicare already covers various hearing health services, it currently does not recognize audiologists as providers, and they will only receive Medicare reimbursement for a limited set of tests to diagnose hearing or balance disorders—provided that patients first obtain an order from a physician or nurse practitioner. 

“The Medicare Audiology Access Improvement Act removes needless government barriers so Americans can access hearing care directly and affordably,” says Senator Paul. “It shows that when Congress focuses on practical solutions, we can work across the aisle to improve healthcare.”

“Outdated Medicare rules are preventing seniors from accessing the vital services audiologists provide,” says Senator Warren. “We’re introducing this bill because older Americans and people with disabilities deserve access to the full range of care they need.”

The Medicare Audiologist Access Improvement Act of 2025 would reclassify audiologists as “practitioners” in the Medicare program, allowing Medicare beneficiaries to receive hearing and balance healthcare services from licensed audiologists.

“I’m proud to have helped improve access to high-quality and affordable hearing aids through the Over-the-Counter Hearing Aids Act in 2017. However, millions of Americans are affected by hearing loss, and more work needs to be done to reduce barriers,” says Senator Grassley. “I’m glad to join my colleagues in introducing this bill to expand access and allow more seniors and individuals with disabilities to get help from a trained audiologist.”

Legislator Support

The legislation is co-sponsored by Senators Jeanne Shaheen (D-N.H.), Amy Klobuchar (D-Minn.), Cory Booker (D-N.J.), Peter Welch (D-Vt.), and Angus King (I-Maine).

“Senior citizens deserve access to high quality audiology care and services they need,” says Senator Booker. “Too many patients suffering from hearing problems struggle to access care because current Medicare rules limit the range of services available. This legislation will remove barriers to accessing audiology care, expand the treatments available, and allow more audiologists to participate in Medicare.”

“Too many Granite Staters suffering from hearing loss are met with bureaucratic barriers when trying to access the care that they need. Roughly one in every three adults between the ages of 65 and 75 experience hearing loss – and yet, they struggle to get care because Medicare does not recognize audiologists as providers,” says Senator Shaheen. “It’s past time we cut through this red tape to expand Medicare and ensure that older adults and Granite Staters with disabilities have access to the health services provided by audiologists. That’s why I’m proud to work across the aisle to introduce bipartisan legislation that does exactly that.”

“Excessive red tape has made it increasingly difficult for more than 70,000 Vermonters who experience hearing loss and need access to audiology services. Outdated Medicaid rules make it harder for folks in every state to receive the crucial care audiologists provide,” says Senator Welch. “I’m proud to join my colleagues in reintroducing this bipartisan legislation to make it easier for seniors and folks with disabilities to get the audiology care they need.”

Widespread Association Support

The Medicare Audiology Access Improvement Act is supported by the American Association of Retired Persons (AARP), the Academy of Doctors of Audiology, the American Speech-Language-Hearing Association, the American Academy of Audiology, the Hearing Loss Association of America, the Hearing Industries Association, the Vestibular Disorders Association, the American Tinnitus Association, the National Rural Health Association, and the National Association of Rural Health Clinics.

“The American Speech-Language-Hearing Association thanks Senators Warren, Paul, and Grassley for their continued leadership to ensure seniors have more streamlined and robust access to hearing and balance care provided by audiologists,” says ASHA 2025 President Bernadette Mayfield-Clarke, PhD, CCC-SLP. “ASHA looks forward to supporting their efforts to remove unnecessary bureaucratic barriers that unfairly penalize seniors and prevent them from accessing critical hearing and balance care in a timely and cost-effective manner.”

The American Academy of Audiology’s President Patricia Gaffney, AuD, MPH, stated, “The leadership of these three dedicated senators in advancing audiologic access nationwide reinforces the vital work audiologists do every day to improve hearing and balance health care. For patients, this legislation represents a meaningful step forward—ensuring timely access to the essential services needed for accurate diagnosis and effective treatment of hearing and vestibular disorders.”

“ADA applauds Senator Warren, Senator Paul, and Senator Grassley for championing the Medicare Audiology Access Improvement Act (MAAIA) to remove red tape so that seniors and individuals with disabilities have streamlined access to crucial hearing and balance healthcare services,” says Amyn Amlani, PhD, president of the Academy of Doctors of Audiology (ADA). “Eliminating burdensome pretreatment order requirements and classifying audiologists as Medicare practitioners will allow patients to receive timely, evidence-based care that improves communication, reduces fall risks, and enhances overall quality of life.”

Featured image: Dreamstime

Key Takeaways:

1. Innovative Technology: Harmony hearing aids offer high-quality sound, Bluetooth streaming, tinnitus support, and user-friendly features across three technology levels.
2. Health Impact Focus: The product addresses a growing public health concern by promoting early intervention for hearing loss, which is linked to serious risks like dementia and depression.
3. Comprehensive Care Model: Harmony integrates seamlessly with Birdsong’s broader hearing benefit platform, emphasizing personalized care, accessibility, and long-term support.

Birdsong Hearing Benefits is introducing Harmony—the company’s latest advancement in hearing aid technology, designed to deliver exceptional sound quality, comfort, and performance. Designed for ease, comfort, and connection, Harmony hearing aids offer three technology levels to meet a wide range of hearing needs.

The launch comes at a time when hearing loss is more prevalent than ever, affecting tens of millions of Americans, including over 30% of the population aged 65 and older. With research showing that untreated hearing loss is directly linked to increased risks of falls, depression, and dementia—making early intervention a priority is more important than ever. Despite this, hearing aid adoption remains low. Harmony is designed to bridge that gap by combining intuitive technology with flexible support options, empowering more individuals to hear better, live safer, and stay connected.

Since its inception in 2022, Birdsong Hearing Benefits has focused on providing comprehensive hearing benefit solutions for Medicare Advantage and commercial health plans. By integrating proactive care strategies with advanced analytics, Birdsong aims to improve clinical outcomes and reduce overall healthcare costs associated with untreated hearing loss.

“Introducing Birdsong Harmony hearing aids alongside our already robust suite of services is a natural and necessary evolution of our mission,” says Sharon Fletcher, CEO of Birdsong Hearing Benefits. “By uniting hearing devices with our proactive care model, we’re closing the loop between diagnosis, treatment, and long-term support. We want our members to hear and live better.”

Harmony: Seamless Sound Quality and Streamlined Support

Harmony hearing aids, available to Birdsong members, are engineered to provide a natural listening experience, even in challenging environments. The hearing aids include Bluetooth streaming, tinnitus support, and teleloop compatibility, along with intuitive double push-button controls and both rechargeable and non-rechargeable battery options. The Birdsong app and RemoteLink 2 put control and care at members’ fingertips.

Meeting the Moment in Hearing Health

Approximately 15% of American adults – 37.5 million people aged 18 and over – report some degree of hearing difficulty, yet many go without support. As public awareness grows and hearing technology evolves, millions are turning to hearing devices to reconnect with loved ones, stay engaged at work, and fully participate in daily life. In fact, more than 28 million U.S. adults could benefit from hearing aids, underscoring the critical need for accessible, empowering hearing health solutions.

According to Birdsong Hearing Benefits, the company is proud to help lead this next era with innovative solutions that prioritize accessibility, performance, and ease of use. The new Harmony product reflects the commitment to merging advanced technology with a member-first benefit design to ensure more people can experience the full spectrum of life’s sounds. 

For more information about Harmony hearing aids, visit birdsonghearing.com/hearing-aids.

Key Takeaways:

1. ADA’s position statement calls for hearing benefit plans to be classified as health benefit plans to ensure proper regulation and oversight.
2. The organization highlights gaps in current hearing healthcare policies that prioritize sales over patient-centered care.
3. ADA is mobilizing audiologists, consumers, and policymakers to push for legislative changes to enhance patient access to quality, evidence-based hearing care.

The Academy of Doctors of Audiology (ADA) released a seminal position statement, A Call to Action on Coverage of Hearing Care: Principles for Public Policies that Optimize Patient Outcomes, advocating for substantial reforms in public policy and insurance regulations governing hearing healthcare coverage. 

“Hearing benefit plans and third-party administrators often place hearing aid sales over patient care, undervaluing essential diagnostic and rehabilitative services,” says Stephanie Czuhajewski, MPH, CAE, executive director of ADA. “Because of disparities in oversight of hearing health coverage schemas, patients are frequently left without crucial audiologic services, severely undermining their health and quality of life.” 

A Call to Action on Coverage of Hearing Care: Principles for Public Policies that Optimize Patient Outcomes highlights gaps in accountability for hearing benefit plans and related TPAs, when compared with other benefit programs for medical, vision, and dental coverage, and proposes 30 specific reforms. According to ADA, the most important reform is simply to require hearing benefit plans and TPAs to be classified as “health benefit plans” or a similar classification that will require them to register with each state and be subject to the purview of the State Insurance Commission or similar entity, so that they can be fully regulated as insurance.

“These recommendations support the Audiology 2050 Initiative, which prioritizes patient well-being as its core tenet,” says ADA President Amyn Amlani, PhD. “ADA believes that audiologists should be empowered to provide care based on evidence-based practices and medical necessity, rather than restrictive, one-size-fits-all hearing benefit plans. For example, ADA believes that the fitting fee that an audiologist earns should be based on the type and complexity of the services that they deliver, rather than the type, brand, or price of the hearing aid that they select for the patient—and ADA also firmly believes that consumers and policymakers will agree.”

Not only does A Call to Action on Coverage of Hearing Care: Principles for Public Policies that Optimize Patient Outcomes set forth clear policy recommendations to protect both patients and audiologists, it sets forth a meaningful call to action and a pledge to advocate for these reforms at the state and federal level. 

“It’s time for us step up and stand up to unfair policy and trade practices, and it’s time for policymakers step forward to ensure that consumers with hearing loss have access to safe, effective, and affordable hearing care,” says Dr Amlani.

ADA is seeking volunteer “AuDvocates” to support this policy initiative, emphasizing that broad-based involvement is essential for meaningful legislative and regulatory change. The organization is encouraging consumers, audiologists, and other key stakeholders to volunteer. For more information or to volunteer, contact Stephanie Czuhajewski at sczuhajewski@audiologist.org or at (859) 321-1595.

About the Academy of Doctors of Audiology

The Academy of Doctors of Audiology (ADA) is dedicated to the advancement of practitioner excellence, high ethical standards, professional autonomy, and sound business practices in providing quality audiologic care. For additional resources, or to join, visit www.audiologist.org.

There is now a 3-month extension for teleaudiology and other telehealth under Medicare, but it’s not clear if coverage will continue beyond that date. As of now, after March 31, all bets are off. And even if it’s continued with another extension, there’s always the concern that coverage could be ended at a later date. 

Since Congress expanded Medicare coverage of telehealth in 2020, it has been renewed every year since. But clearly, that is not guaranteed. Congress had been ready to pass a resolution that would have funded the federal government into 2025 and included a two-year extension for expanded Medicare coverage of telehealth. But then some lawmakers changed their minds. 

What is needed is legislation to secure Medicare coverage of all telehealth, including teleaudiology, for the long term. 

Ensuring Equal Access

Of course, telehealth surged in popularity during the COVID-19 pandemic, especially in its early days in 2020. While people do not use this service as much as they did then, it is still in use, and something that many patients have come to rely on. 

This issue is of particular concern to older adults and people in rural areas—and the HCPs who treat these populations. Losing access to teleaudiology would disproportionately affect these people. 

Passing Needed Legislation for Teleaudiology

This is not the first time access to teleaudiology has been in danger of ending, and it likely won’t be the last. This is why the American Academy of Audiology (AAA), Academy of Doctors of Audiology (ADA), and American Speech-Language-Hearing Association (ASHA) have all endorsed the Medicare Audiology Access Improvement Act (MAAIA). This bipartisan legislation was introduced in both the House and Senate in 2023. It was an updated version of previously introduced legislation that had garnered support but had not passed and been signed into law. 

The MAAIA would include audiologists as “practitioners” under the Medicare statute to allow them to continue to provide expanded audiology and vestibular services to Medicare beneficiaries, including telehealth. It would also authorize the CMS to reimburse audiologists for Medicare-covered treatment and diagnostics. It was hoped the stipulations of the legislation would go into effect in 2025. 

What HCPs Can Do

While such legislation hasn’t yet become law, it doesn’t mean that it can’t. Hearing care professionals can help advocate for the legislation needed to protect access—both for the sake of HCPs and their businesses and for their patients who rely on teleaudiology and other forms of telehealth. The same goes for Medicare coverage and reimbursement of audiology services in general. 

If you haven’t already, or even if you have, you can write to your congresspeople and senators imploring them to support such legislation. You can work to push forward legislation as part of any professional organizations you belong to. You can also ask your patients to become advocates. After all, it will greatly benefit patients and HCPs if teleaudiology access is safeguarded for good. 

— Melanie Hamilton-Basich

Melanie Hamilton-Basich is the chief editor of The Hearing Review. You can reach her at mhamilton@medqor.com.

By Beth Kidder, MPP

Choosing to provide services and items to Medicaid beneficiaries is an important decision for hearing care professionals. More than 21% of the population in the United States, including over 39% of children and youth younger than age 19, are enrolled in Medicaid. As healthcare providers, it is critical that audiologists and hearing instrument specialists understand regulations for delivering services or items to patients with Medicaid coverage. Misinterpretation of the regulations may discourage providers from participating in Medicaid programs. This decision would limit access to important hearing services and items for Medicaid beneficiaries across communities.

Inaccurate information is circulating among some audiologists and hearing instrument specialists about “best pricing” requirements associated with Medicaid participation. Best pricing in this context is interpreted to mean the amount providers charge Medicaid (or Medicaid managed care organizations) for services or items delivered is the maximum amount that they can charge other payors (non-Medicaid) for those same services or items. This misperception is resulting in a belief that providers are prohibited from charging more for services and items provided to non-Medicaid patients than they charge for those same services and items rendered to Medicaid patients. No federal regulation requires this type of best pricing, and it is highly unlikely that state regulations would require it.

Clarifying Federal Regulations

Federal Medicaid regulations require providers who deliver services or items to Medicaid enrollees to accept reimbursement from Medicaid as payment in full for Medicaid-covered patients.¹ Providers are prohibited from requesting and accepting additional payment, above and beyond what they charge to Medicaid and any applicable co-pays, for a service or item that is delivered to a patient who is a Medicaid member.

A federal regulation also provides authority to the U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) that discourages providers from charging Medicare or Medicaid substantially in excess of their usual charges.² More specifically:

The OIG may exclude an individual or entity that has—

(1) Submitted, or caused to be submitted, bills or requests for payments under Medicare or any of the State health care programs containing charges or costs for items or services furnished that are substantially in excess of such individual’s or entity’s usual charges or costs for such items or services.³

The OIG is the arm of the federal government that leads efforts to combat fraud, waste, and abuse in HHS programs. Providers that charge Medicare or state health care programs (Medicaid) substantially more than their usual and customary charges or costs may be excluded from these programs. Excluded providers cannot receive any federal healthcare program payment for services or items they furnish or prescribe.⁴

A Medicare fraud and abuse publication from the Centers for Medicare & Medicaid Services (CMS) further emphasizes this point, citing “charging excessively for services or supplies” as an example of abuse. Like the federal law and regulations, it does not require providers to accept the same reimbursement across payers.⁵ Thus, while it is important that providers only charge Medicaid the amount they would usually charge other payors, there are no federal requirements to restrict charges to other payers to a Medicaid rate.

To support transparency and compliance with regulations, providers who bundle services for their general patient population should itemize their Medicaid charges. This will enable a comparable comparison of charges regardless of the codes used. For example, itemizing will ensure that the comparison of total Medicaid charges for a hearing aid are for the same make, model, technology, and style of hearing aid, along with the same level and duration of care.

Medicaid Access to Care Requirements

Federal Medicaid regulations require states to ensure sufficient access to care. Under federal law, state Medicaid programs must ensure that:

…[P]ayments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available…at least to the extent that such care and services are available to the general population in the geographic area.⁶

In addition, the new federal Ensuring Access to Medicaid Services Final Rule⁷ enacts major provisions to ensure timely access to high-quality care. The new rule requires states to demonstrate sufficient access to care in key circumstances. The existing federal law and this new rule argue against states imposing blanket payment restrictions, such as best pricing requirements, which would limit the number of providers enrolled in Medicaid or cause providers to limit the number of Medicaid patients they serve.

Most providers who participate in Medicaid also accept and bill other payors. It is rare that a provider will only accept Medicaid due to the historically lower reimbursement. If Medicaid participating providers were required to accept Medicaid’s payment fee across all payers, it would severely impact a Medicaid program’s ability to attract the providers necessary to ensure sufficient access to care for Medicaid enrollees.

State Medicaid and Managed Care Organization Regulations May Vary

Providers should always follow the specific guidance of the state Medicaid program in addition to carefully reviewing the coverage specifics of managed care organizations with which they participate. Each state may establish its own pricing within federal guidelines. Although the Medicaid access to care federal mandate described earlier makes it unlikely any individual state will have a best pricing requirement for Medicaid participating providers, the rule does not explicitly prohibit it. 

One example of state-specific pricing is Michigan Medicaid. Michigan obtains a reduced price for hearing aids through contracting with one vendor to provide hearing aids for the entire state. Another example is Florida, where the law governing Florida health maintenance organizations (HMOs)⁸ confirms that these entities do not have to reimburse providers at the same payment rates a provider receives from Medicaid or Medicare or otherwise limit the amount an HMO can pay. In fact, the Florida law ensures flexibility in provider reimbursement. It prohibits an HMO from requiring a contracted healthcare practitioner to accept the terms of other healthcare practitioner contracts with the HMO, other insurers, or another HMO, under the management and control of the HMO, including Medicare and Medicaid provider contracts. This provision includes contracts with audiologists.

Conclusion

Federal regulations require providers who participate in the Medicaid program to:

• Accept payment from Medicaid as payment in full for Medicaid-covered patients
• Not charge Medicare or Medicaid substantially in excess of usual and customary charges

A thorough examination of federal regulations demonstrates that there is no regulation or requirement that providers participating in Medicaid must apply the same Medicaid rate across other payers. In fact, imposing this restriction would limit the number of providers available to Medicaid patients and therefore hinder access to care. This would hamper a state’s ability to comply with federal access to care laws and regulations.

Of course, state regulations vary and, though it is unlikely, no explicit regulation prevents a state from imposing a best pricing requirement. Providers should check state-specific regulations to verify that their state Medicaid program does not restrict the amount providers charge for services or items delivered to non-Medicaid payors to the amount charged to Medicaid (or Medicaid managed care organizations) for the same services or items.

Beth Kidder, MPP, is the managing principal for the Health Management Associates Florida Office located in Tallahassee. She has more than 20 years of experience supporting state Medicaid programs across the country, and as Florida’s former deputy secretary for Medicaid, she has subject matter expertise in all aspects of Florida’s Medicaid program. Correspondence can be addressed to Beth Kidder at bkidder@healthmanagement.com.

References

1.  Code of Federal Regulations. Acceptance of State payment as payment in full. 42 CFR 447.15. Published 2024. Available at: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.15. Accessed October 21, 2024.

2.  Code of Federal Regulations. Amount of payment if customary charges for services furnished are less than reasonable costs. 42 CFR 413.13. Published 2024. Accessed October 27, 2024. Available at: https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-413/subpart-A/section-413.13.

3.  Code of Federal Regulations. Excessive claims or furnishing of unnecessary or substandard items and services. 42 CFR 1001.701. Published 2024. Available at: https://www.ecfr.gov/current/title-42/chapter-V/subchapter-B/part-1001/subpart-C/section-1001.701. Accessed October 21, 2024.

4.  Office of the Inspector General. Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs. U.S. Government Accountability Office. Update issued May 8, 2013. Available at: https://oig.hhs.gov/exclusions/files/sab-05092013.pdf. Accessed October 21, 2024. 

5. Centers for Medicare & Medicaid Services. Medicare Fraud & Abuse: Prevent, Detect, Report. Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Fraud-Abuse-MLN4649244.pdf. Accessed October 21, 2024. 

6.  Social Security Administration. State Plans for Medical Assistance. Available at: https://www.ssa.gov/OP_Home/ssact/title19/1902.htm. Accessed October 21, 2024.

7.  Centers for Medicare & Medicaid Services. Final Rule: Medicaid Program; Ensuring Access to Medicaid Services. Federal Register. May 10, 2024;89(92). Available at: https://www.federalregister.gov/documents/2024/05/10/2024-08363/medicaid-program-ensuring-access-to-medicaid-services. Accessed October 21, 2024.

8.  Florida Legislature. Stat. § 641 (2024). Available at: Chapter 641, Florida Statutes. Accessed October 21, 2024.

Featured image: Dreamstime

Takeaways

1. Expanded Eligibility: Tricare’s new hearing aid coverage includes children of retired service members enrolled in Tricare Prime, offering benefits for biological, adopted, stepchildren, or court-placed dependents under 21 (or 23 for full-time students).
2. Retroactive Coverage: The benefit applies retroactively to services received on or after Dec. 22, 2023, allowing families to file claims for reimbursement through their regional contractors.
3. Eligibility Criteria: Children must demonstrate a hearing loss of at least 26 decibels in one or both ears through a hearing test, emphasizing the program’s focus on addressing qualifying medical needs.

Tricare, a government-managed health insurance program for military personnel, their families, and other eligible individuals recently expanded its hearing aid coverage to include eligible children of retired service members. 

Providing Pediatric Hearing Care

This new coverage results from a new statute. It aims to improve access to life-changing medical technology and help eligible children of retired service members get the hearing aids they need.

“Before the passage of the National Defense Authorization Act, TRICARE coverage of hearing aids was limited to dependents of active duty service members with qualifying hearing loss,” says Erica Ferron, management and program analyst, TRICARE Health Plan, at the Defense Health Agency. “Now, more TRICARE beneficiaries will be able to receive hearing aids and services.”

Keep reading to learn about eligibility, coverage, and more.

Who is eligible?

For retirees, their children may qualify for hearing aid coverage if:

• They’re entitled to retired or retainer pay, or equivalent pay; and
• Their child is enrolled in TRICARE Prime. This includes the US Family Health Plan, as described in the TRICARE Plans Overview Fact Sheet.

The benefit covers unmarried children of living sponsors who are:

• Under 21 years old, or
• A full-time college student aged 21-23, or
• Unable to support themselves due to a disability that started before age 21 (or before 23 if they were a student)

This includes:

• Biological children
• Adopted children
• Stepchildren
• Children placed in your legal care by a court

Determining Qualification

To get coverage for hearing aids, your child needs to take a hearing test. They must demonstrate at least 26 decibels of hearing loss in one or both ears.

Important Things to Know

• The child must be enrolled in TRICARE Prime or the US Family Health Plan.
• Coverage is retroactive to Dec. 22, 2023. If a child got hearing aids or services on or after that date, you can file for reimbursement for TRICARE covered services. But it won’t happen automatically. You must file a claim with your regional contractor.

Further Reading

Considering Special cases

For whoever is interested in exploring TRICARE’s expanded coverage of hearing aids, please note that the coverage isn’t available overseas. If the child lives in the U.S. but travels overseas, they can keep their coverage, but they need special approval for overseas care.

TRICARE doesn’t cover hearing aids for retirees. Those who are interested may, however, qualify for other special programs. Check out TRICARE’s hearing aids page to learn more.

For a child to get this benefit, they must have TRICARE Prime and a qualifying hearing loss. The ability to hear properly is essential for your child’s social and physical development.

Photo: Dreamstime

Lower-income Medicare Advantage beneficiaries struggle more with affording dental, vision, and hearing services despite enrolling in plans that cover these benefits, according to a study published in Health Affairs.

Key Takeaways:

1. Lower-income adults enrolled in Medicare Advantage plans face more cost barriers for dental, vision, and hearing care than higher-income beneficiaries.
2. Higher star ratings in Medicare Advantage plans improve dental coverage but not necessarily hearing and vision coverage.
3. The study calls for better oversight of rebate payments to ensure equitable access to supplemental benefits for all enrollees.

Lower-income adults with Medicare Advantage plans are more likely to have difficulty paying for dental, vision, and hearing services than higher-income beneficiaries—despite enrolling in plans that cover these benefits, according to a new study published in Health Affairs.

Medicare Advantage plans offer a private insurance alternative to traditional Medicare coverage for health insurance. The most common supplemental benefits are dental, vision, and hearing, with more than 90% of Medicare Advantage plans providing coverage for one or more. These supplemental benefits, which are not available through traditional Medicare, are largely funded by rebate dollars paid by the Centers for Medicare and Medicaid Services (CMS) to the private insurers. 

“The high need for dental, vision, and hearing care among Medicare recipients drives the high demand for supplemental benefits,” says Avni Gupta, a health policy researcher who recently earned her PhD in health policy and management from the NYU School of Global Public Health and is now at the Commonwealth Fund. “However, these added benefits are expensive for Medicare, which pays nearly $20 billion a year in rebates to Medicare Advantage insurers for supplemental benefits.”

High Costs Still a Barrier for Low-Income Beneficiaries

An increasing number of low-income older adults are enrolling Medicare Advantage plans over traditional Medicare plans—a shift that may be driven by the supplemental benefits available in these plans. However, supplemental benefits may not provide full financial protection, as beneficiaries still face relatively high out-of-pocket costs and forego needed dental, vision, and hearing care. 

To understand whether coverage for supplemental benefits through Medicare Advantage is meeting the needs of those enrolled, the researchers analyzed nationally representative data from a 2018-19 survey of Medicare Advantage beneficiaries. They analyzed differences by income and the plans’ star ratings, a measure of quality. 

The researchers found that lower-income Medicare Advantage beneficiaries are more likely to experience cost-related barriers in accessing dental, vision, and hearing services than higher-income beneficiaries, even after adjusting for several measures of benefit generosity. Overall, nearly 11% of beneficiaries reported unmet dental need, 4% reported unmet vision need, and 2% reported unmet hearing need because of cost.

Impact of Star Ratings on Coverage and Access

The researchers also found that enrolling in higher-quality Medicare Advantage plans—those with the highest star ratings—was associated with lower unmet needs for dental services overall and for lower-income groups, meaning that higher star ratings translated to better dental coverage. This was not true for hearing and vision coverage.

However, despite CMS making higher rebate payments to Medicare Advantage plans with high star ratings, the positive impact of star ratings on dental coverage was not found to be driven by these bonus payments. 

“This raises questions about whether the higher rebate payments to highly rated Medicare Advantage plans in the form of the quality bonus payments actually improve access to the funded services for beneficiaries,” adds Gupta.

Calls for Improved Oversight and Accountability in Medicare Advantage

The researchers note that CMS should consider measuring and monitoring the coverage, quality, and equity of supplemental benefits in order to make coverage more equitable and better link rebate payments to the value of supplemental benefits for Medicare Advantage enrollees.

“As the popularity of Medicare Advantage plans continues to increase, there is a need for more accountability and better oversight on how rebate dollars are being used to improve equitable access to supplemental benefits covering services we all use and need, such as dental, hearing, and vision care,” says José A. Pagán, a professor and chair of the Department of Public Health Policy and Management at the NYU School of Global Public Health. “Good stewardship in rebate payments means that Medicare Advantage beneficiaries should get the highest possible value as a result of financial incentives.”

In addition to Gupta and Pagán, study authors include Diana Silver of the NYU School of Global Public Health, Sherry Glied of NYU’s Robert F. Wagner Graduate School of Public Service, Kenton Johnston of Washington University in St. Louis, and David Meyers of Brown University School of Public Health.

Image: Dreamstime

Takeaways:

1. Expanded Insurance Portfolio: ESCO has added three new types of insurance—BOP, workers’ compensation, and cyber security—to its services, targeting the specific needs of hearing healthcare business owners.
2. Comprehensive Business Protection: The new BOP offered in partnership with AmTrust provides property and liability coverage that includes protection against theft, fire, and accidents, while the workers’ compensation insurance covers medical costs, disability benefits, and legal fees related to work injuries.
3. Enhanced Cyber Security Insurance: Given the rise in data breaches and cyber threats, ESCO’s cyber security insurance is designed to protect businesses from losses related to technology breaches.

ESCO is expanding their insurance solutions for business owners. ESCO is now offering a business owner’s policy (BOP), workers’ compensation, and cyber security insurance. ESCO’s comprehensive insurance solutions are specially designed and focused for hearing healthcare business owners.

“Since our inception 35 years ago we have been committed to offering comprehensive hearing device protection,” says Jim Guthier, owner, ESCO. “Expanding our insurance services to owners of audiology and hearing healthcare practices is a very natural progression for our business model and team.”

Business Owner’s Policy

Partnering with AmTrust, our BOP insurance includes property and liability coverage to protect business owners against theft, fire, unexpected accidents, and more. If an employee gets injured on the job, AmTrust will have you covered through their workers’ compensation insurance. It covers medical costs and care, disability benefits, ongoing care, and work-related injury legal fees.

Addressing Cyber Security

With cyber security insurance, you can be rest assured that your business will be protected against losses that are computer or technology related. This could be due to a phishing or ransomware attack, or because a laptop containing sensitive information was lost or stolen.

“These types of attacks are happening more frequently than ever. We saw a 72% increase in data breaches from 2021 to 2023 with more than 343 million victims. If you have a business that collects consumer data, has accounts payable and receivable, and maintains a website, you are at risk and need cyber security coverage,” says Guthier. 

Further reading: Sycle and ESCO Partner on New Warranty Reminder Program for Hearing Clinics

Photo: Dreamstime

“CMS recognizes that providers and suppliers may face significant cash flow problems from the unusual circumstances impacting facilities’ operations, preventing facilities from submitting claims and receiving Medicare claims payments when using the Change Healthcare platform,” according to a press release. “CMS has heard these concerns and is taking direct action to support the important needs of the health care sector.” 

CHOPD Accelerated Payments

On March 9, 2024, CMS made available Change Healthcare/Optum Payment Disruption (CHOPD) accelerated payments to Part A providers and advance payments to Part B suppliers experiencing claims disruptions as a result of the cyberattack. The CHOPD accelerated and advance payments may be granted in amounts representative of up to 30 days of claims payments to eligible providers and suppliers. 

Further Reading: Cyber Attacks and How to Protect Your Practice: An Interview with Ridge Sampson of Sycle.net

The average 30-day payment is based on the total claims paid to the provider/supplier between August 1, 2023 and October 31, 2023, divided by three. These payments will be repaid through automatic recoupment from Medicare claims for a period of 90 days. A demand will be issued for any remaining balance on day 91 following the issuance of the accelerated or advance payment. 

Staying Up to Date on CMS Assistance

CMS stated that it will continue to monitor the incident and its impact, and advised that providers and suppliers should continue to work with all their payers regarding how to receive timely payments, and any additional short term funding programs offered through other payers.

According to the release, CMS has encouraged MA organizations to offer advance funding to providers most affected by this cyberattack. 

For more details, including eligibility requirements, visit the CMS fact sheet. 

According to court documents and statements made in court, Dellaghelfa is a licensed hearing instrument specialist and the owner of General Hearing, a Waterbury-based hearing aid dealer. Since approximately 2013, General Hearing has been a participating provider enrolled in the Connecticut Medical Assistance Program (CTMAP), Connecticut Department of Social Services-administered program that provides medical assistance to low-income persons. CTMAP’s benefit packages, referred to as “HUSKY” or “Connecticut Medicaid,” are jointly funded by the State of Connecticut and the federal government.

From approximately June 2016 to April 2022, Dellaghelfa submitted, or caused to be submitted, false and fraudulent claims for payment for services and equipment that were not provided or were medically unnecessary. For example, in November 2018, Dellaghelfa submitted claims to Connecticut Medicaid for services provided to six patients during a period of time that Dellaghelfa was traveling outside the U.S. In 2019 and 2020, some of the fraudulent claims involved services that were purportedly provided by his three employees. However, Dellaghelfa knew that the employees performed hearing tests without having the required professional permit, and submitted paperwork for hearing tests and services that did not occur or were not medically necessary.

In addition, in violation of the CTMAP provider agreement, Dellaghelfa paid third-party “patient recruiters” for each Medicaid patient they brought to General Hearing for a hearing test, and that then failed the hearing test and received hearing aids. He also submitted false claims to Connecticut Medicaid for testing and hearing aids for five of the patient recruiters who did not need hearing aids.

Judge Thompson ordered Dellaghelfa to pay restitution of $6,141,857 to the Connecticut Medicaid program. As part of his restitution obligation, Dellaghelfa agreed to forfeit $332,675 held in personal and business bank accounts.

On February 9, 2023, Dellaghelfa pleaded guilty to healthcare fraud.

Dellaghelfa, who is released on bond, is required to report to prison on October 10.