MEDICAID and SCHIP Programs
For a listing of each state’s Medicaid contacts:
Medicaid is health insurance for people with very low income. SCHIP is your State Children’s Health Insurance Program. It is available for people with higher incomes than Medicaid. Each state establishes its own criteria. In some states, people with very low income may qualify for hearing aids through Medicaid. People with higher income may temporarily qualify for assistance with medical expenses, including hearing aids, through the “medically needy program” administered by the county social service agency. Look in the Government section of the telephone book under County Social Services, and request an appointment to determine your eligibility for Medicaid and SCHIP.
This web site has a listing state by state of who covers what and under what circumstances:
Overview: Medicaid and Hearing Aids
Most states establish minimum hearing loss criteria for initial and replacement hearing aids, and many require a medical exam as well as an audiological evaluation to determine if a hearing aid is medically appropriate. Some states limit the types of hearing aids covered, and many establish a limit on the number of aids and accessories, such as batteries, that beneficiaries may receive within a particular period of time. Some states allow interim replacements or repairs if aids are lost or broken. Often, prior approval requirements are implemented to assure compliance with these standards.
Federal law and regulations related to the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program require states to provide medically necessary services for children. Accordingly, items such as hearing aids are generally covered more frequently for children than for adults. Further, services that may not be covered for adults, e.g., binaural hearing aids, are often available for children, although states may use a prior approval process to assure medical necessity and appropriate utilization.
The predominant reimbursement methodology used by states for hearing aids is “fee for service”. This means the state has established a maximum payment amount for a particular item or service and pays the lesser of the provider’s charge or this amount. Often the payment is capped by an estimate of cost. Several states accept and pay “reasonable charge” or pay the provider’s “acquisition cost” plus a dispensing fee. States may also require that hearing aids be purchased from a vendor that has agreed to provide the aids at a reduced price through a volume purchase contract.
Overview: State Childrens’ Health Insurance Program (SCHIP)1
In contrast to Medicaid, by design, S-SCHIP functions more like a private insurance policy and thus addresses the needs of generally “healthy” children. It is not an entitlement to individual children, and benefits may be less comprehensive in scope, amount and duration than Medicaid benefits, with some cost-sharing allowed. The medical necessity standard can be more restrictive than the “preventive” medical necessity standard used in Medicaid, limiting coverage of services to those that are restorative. Grievances and appeals may be less defined. And services not provided by Managed Care Organizations must be found elsewhere in the system, e.g., through state public health agencies.
Despite the variation just described, the majority of insurers made up for the limitations of the S-SCHIP benefit package designed by states and reflected in their contracts and would have provided coverage beyond the limits and exclusions of S-SCHIP for the majority of services examined here. This was particularly true for case management/care coordination for both children, which almost all insurers would have covered without limitations, when states limited or excluded this service. This was also the case for both children for the three prescription drugs studied, speech and language evaluation, hearing aids, fitted wheelchairs, and pumps for overnight feedings, which two-thirds of the insurers would have covered without limits (compared to states that unanimously limited these services). Finally, insurers were also more generous in their coverage of enabling transportation than states, all of which excluded coverage of this service, albeit with some more variation (about a third would have covered it without limits and another fifth with some limits).
This finding would indicate that insurers may provide, perhaps routinely, extra-contractual services by overriding otherwise applicable limits in the case of higher needs children, even though the premium they receive is not calibrated to tolerate this type of practice. On the other hand, certain services most needed by Children with Special Health Care Needs (CSHCNs), such as speech and physical therapy, motorized wheelchairs, and assistive communication devices, were generally restricted under S-SCHIP by both states and insurers in ways permissible under S-SCHIP but not permissible under Medicaid in the case of children. In addition, several insurers also excluded these services, seemingly against what the SCHIP programs called for.
1Source: Anne Markus, J.D., Ph.D.,* Sara Rosenbaum, J.D.,* Ruth E.K. Stein, M.D.,‡ Jill Joseph, M.D., Ph.D., “From SCHIP Benefit Design to Individual Coverage Decisions,” Policy Brief #6: SCHIP Coverage Decisions, Center for Health Services Research and Policy, Department of Health Policy, George Washington University, School of Public Health and Health Services, Washington, D.C., 2006
Advice for people navigating these systems:
- Find out if you are eligible for services, preferably before an emergency arises.
- If a denial is made that you consider unreasonable, and you can make a case that coverage of hearing aids or cochlear implants, or bilateral cochlear implants would provide the child with greater functionality both now and as an adult, you should definitely appeal.
- If a denial is made and you can make a case that providing an adult with hearing aids or a cochlear implant would make that person employable, you should definitely appeal.
- Find an advocate to work with you.
- Be reasonable and polite. People will be more likely to decide in your favor if you are. If you are too angry to be reasonable and polite, wait until you have calmed down before approaching the decision makers again.
- Whenever possible, produce research documenting the importance of amplification and/or bilateral amplification. Your hearing healthcare provider will probably be able to help you. There also may be research posted on the Better Hearing Institute website that will be helpful for your argument.
For more information on Medicaid: http://www.cms.hhs.gov/MedicaidEligibility/Downloads/MedicaidataGlance05.pdf
For more information on SCHIP: http://www.cms.hhs.gov/LowCostHealthInsFamChild/
To locate your state’s contact information: http://www.cms.hhs.gov/LowCostHealthInsFamChild/downloads/StateSCHIPDirectors.pdf