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MAASA Gains Steam in the Fight for Equal Audiology Access

Jong, Kelly

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doi: 10.1097/01.HJ.0000752288.19883.d3
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The Medicare Audiologist Access and Services Act (MAASA) will improve access to Medicare-covered audiology services for Medicare Part B beneficiaries and more effectively deploy audiologists within the Medicare system to help their patients,” Stephanie Czuhajewski, MPH, CAE, Executive Director of the Academy of Doctors of Audiology said. “MAASA is an evidence-based, cost-effective, common-sense policy.” The legislation, originally introduced in 2019 and again in March of this year, has seen great bipartisan support, with 25 original cosponsors in Congress upon reintroduction—more than triple the number it saw in 2019. “As more policymakers and patient advocates become aware of the great need for these common-sense improvements, momentum for the legislation will continue to increase,” Czuhajewski said.

iStock/CatLane. Audiology, medicare, healthcare.


The Medicare Audiologist Access and Services Act of 2021 aims to enhance the Medicare benefit by providing critical direct access to both diagnostic and therapeutic services provided by audiologists, said House of Representative members and bill co-sponsors Tom Rice (R-SC) and Matt Cartwright (D-PA). The bill promises to remove unnecessary barriers, allowing patients to receive appropriate, cost-effective, and timely audiology care that will improve outcomes for beneficiaries by allowing direct access to audiologic services. It will streamline Medicare coverage policies so audiologists can provide the full range of Medicare-covered diagnostic and treatment services that correspond to their scope of practice and reclassify audiologists as practitioners, which is consistent with the way Medicare recognizes other non-physician providers, such as clinical psychologists, clinical social workers, and advanced practice registered nurses, per the legislation. The bill will ensure that Medicare beneficiaries have access to the same level of audiological care available in the Veterans Health Administration under the Federal Employees Health Benefits Program and under private insurance.

“When first introduced in 2019, the bill received significant bipartisan support in the House and Senate from members across the political and ideological spectrum, gaining 65 House cosponsors and 8 in the Senate,” said Jerry White, the director of Federal Affairs and Health Care at the American Speech-Language-Hearing Association. Since its original introduction, key provisions of the bill to enable audiologists to provide treatment services and appropriately classify audiologists as practitioners were included in House-passed prescription drug legislation (H.R. 3)—a major win toward equal access to care, he added. But though the legislation has seen some success, the need for MAASA support is stronger than ever, as barriers to care, especially during the COVID-19 pandemic, continue to grow. With patients seeking less care, disparities in access deepening, and risk of comorbidities like social isolation on the rise, the audiology community must rally around this step into the future of care.


The current standard for care, which classifies audiologists as suppliers and limits care for Medicare Part B beneficiaries, poses several risks to patients. “The challenges Medicare's outdated restrictions pose are two-fold,” White explained. “First, it creates unnecessary barriers for beneficiaries who need access to the critical hearing and balance care audiologists are licensed to provide in every state. Second, it prevents these hearing health care professionals from performing within the full scope of their practice.”

Angela Shoup, PhD, the president of the American Academy of Audiology, explained that several classification inconsistencies in the current model prevent equal access to care. For example, audiologists are considered suppliers—“A classification that has outlived the evolution of the profession since Medicare was created,” she said. “This classification has limited Medicare-covered services to diagnostic only, even though audiologists are licensed in all 50 states to provide both diagnostic and treatment services.”

Additionally, audiology services are classified as “diagnostic other” within the Medicare Part B system, meaning audiologists cannot be reimbursed for Medicare-covered treatment services that they are licensed to provide, Czuhajewski said. “So, even though Medicare covers services such as cerumen removal, aural rehabilitation, and vestibular rehabilitation, and even though audiologists are licensed and qualified to perform those services, traditional Medicare patients must either be referred to another provider or must pay privately for the services.” This coverage inequity often results in delayed treatment, unwarranted costs, and frustration for beneficiaries, she said. Even for those patients who only suspect they're suffering an audiologic issue such as a hearing or balance disorder, a physician order is required prior to seeking care and in order for services to be eligible for coverage. “This can be an expensive, time-consuming process for the beneficiary and their caregiver, and results in unnecessary, duplicative services within the Medicare system,” Czuhajewski said.

White noted that these inefficiencies can lead to unmanaged conditions that negatively impact patient health and wellbeing. “Medicare is extremely outdated in how it treats audiologists and audiology services and has not evolved in the way that other public and private payers have,” Shoup lamented. “Given the prevalence of hearing loss in the Medicare population and the linkage of untreated hearing loss to increased risk of falls and cognitive decline, the provisions of this bill are long overdue.”


These risks to patient health are even more pronounced in light of the COVID-19 pandemic, which has seen a heavier reliance on telehealth models resulting from safety measures and patient discomfort with the traditional office appointment. When the pandemic hit, the “supplier” classification under the current Medicare standard meant that many audiology practices were deemed “nonessential” and therefore had to close or stop seeing patients. “The Academy of Doctors of Audiology and audiology patients never considered audiologists to be non-essential, even during the height of pandemic closures,” Czuhajewski said. “It is true that audiology clinics were among the health, medical, and surgical clinics that were closed for face-to-face, in-clinic testing and treatment, but audiologists were working harder and more diligently than ever to assist their patients. From counseling to curbside repairs, audiologists went above and beyond for their patients to ensure that they could get the essential care that they needed during the pandemic, even in cases where the audiologist could not seek insurance reimbursement for the services.” Czuhajewski added that though procedures that required an in-person visit or that were routine were appropriately postponed, audiologists, as clinical doctors, used their best professional judgment to safely and effectively help their patients. “There is nothing nonessential about that,” she said.

Shoup added that even under the best circumstances, Medicare beneficiaries face significant barriers in accessing the services of an audiologist—the pandemic and ensuing shutdowns only further served to highlight the flaws in the Medicare treatment of audiologists and audiology services. “The existing ‘gatekeeper’ requirement that necessitates a beneficiary obtaining a physician order prior to being allowed to access an audiologist was magnified once the pandemic began,” she said. “Not only did this introduce an additional required visit and potential exposure touchpoint before a patient could receive the services they need, but general practitioners were overwhelmed with other priorities and patients were similarly afraid to venture into a physician's office to receive a referral.”

This had the effect of beneficiaries simply forgoing needed care, Shoup assessed. “When you think about it, the need to be able to hear and communicate is paramount during a public health emergency in order to be able to understand the advice of medical professionals and safety measures,” she said. “Also, many older persons, particularly in assisted living facilities, were effectively isolated from family and friends.”


One way to address the inability or hesitance of patients to make audiology appointments related to COVID-19 is by offering telehealth. “The reclassification to ‘practitioner’ under the MAASA bill will enable audiologists to furnish services through telehealth, which currently is only allowed to a limited extent during the COVID-19 public health emergency,” White said. “Congress provided this temporary authority to the Department of Health and Human Services (HHS) in the CARES Act, but HHS has only covered limited diagnostic services audiologists provide and this authority expires when the public health emergency ends.”

White stated that the enactment of the MAASA bill would ensure that, once the pandemic is over, seniors will have the ability to obtain services provided by telehealth when clinically appropriate on a permanent basis, which will both help deter the spread of COVID-19 and help those who live in rural or medically underserved areas, or who have transportation or mobility challenges, get the hearing and balance care they need when they need it.

In addition to limiting access to care, the current standard imposes costs on the health care system that aren't related to actually providing care, White said. “Streamlining access to this critical care will save consumers more than $36 billion in out-of-pocket costs over 10 years simply by eliminating co-pays for unnecessary doctor visits, and taxpayers could save $108 million over 10 years by preventing unnecessary federal healthcare spending,” he said.


From a clinician standpoint, MAASA will improve beneficiary access to audiologists in every practice setting where Medicare Part B beneficiaries are seen, and will allow audiologists to deliver high-quality, efficient services along the continuum of care, Czuhajewski said. “MAASA will also allow audiologists and the Medicare system to measure quality and patient outcomes more effectively.” Shoup added that at the most basic level, audiologists would be able to provide and be reimbursed for both diagnostic and treatment services, while under the current Medicare standard, audiologists are only able to provide and bill for a very limited number of diagnostic services.

“Importantly, MAASA will not add any new services into the Medicare system,” Czuhajewski noted. “Since audiologists are already responsible for determining medical necessity within Medicare, the bill will not result in inappropriate increases in utilization of services.” She clarified that MAASA will not change an audiologist's scope of practice or licensure in any way, as licensure and scope of practice are determined by each state independently. Instead, “reclassifying audiologists as practitioners in Medicare will allow them to be better deployed,” she said. White added that the bill will not impact Medicare's reimbursement for these services or increase beneficiary costs. “Medicare already covers these services when furnished by a physician or other practitioner, and the bill simply ensures that audiologists are also able to provide and receive the same payment for those services as any other practitioner who provides them under Medicare,” he said.


Though MAASA has received bipartisan support in Congress, it is vital that the audiology community and its patients voice support, urging legislators to pass the bill so all patients can receive equal access to care. Shoup noted that some potential obstacles may challenge the bill's successful implementation, including some legislators or groups that perceive the bill to be an expansion of Medicare, and as a result could have concerns about what that may mean in terms of cost to the federal government. “The best way that audiologists can convince them otherwise is to emphasize that the Medicare Audiologist Access and Services Act does not add any new services to Medicare, does not change the scope of practice for audiologists and would provide cost savings by eliminating the current physician referral requirement,” she said. In fact, a commissioned study found that the overall “cost” of the legislation to the federal government would be extremely modest. “More accurately, passage of this legislation would be an example of Medicare modernization—simply bringing Medicare audiology benefits and access in line with other federal programs as well as many private payers,” Shoup said.

White added that though supporters are optimistic about the bill's advancement, “The hyper-partisan atmosphere that exists on Capitol Hill right now and the resulting lack of regular order in the House and Senate is an obstacle that must be overcome for the bill's enactment into law.” Both parties must be willing to work together on key legislation, especially on issues such as increasing access to critical healthcare services like those provided by audiologists,” White said. To show support for the legislation, audiologists should encourage their colleagues and patients to reach out and make their voices heard.

“Audiologists and their patients can have a tremendous impact on advancing the legislation, and we encourage every audiologist to take action to give their members of Congress an earful about the importance of access to audiology services for their Medicare patients,” Czuhajewski said. When speaking to colleagues or patients about the legislation, Shoup recommended this quick summary: “The MAASA bill makes sense as it improves access to care for Medicare patients, brings Medicare procedures more in line with other private and public insurers, modernizes outdated provider classification, and decreases inefficiencies for healthcare providers and patients.”

While the bill continues to gain momentum and bipartisan support in the U.S. House of Representatives, and supporters look forward to an introduction in the U.S. Senate, it is impossible to predict the exact timing or temperament of Congress as it relates to passage and enactment of MAASA, Czuhajewski said. To show support, contact your Congressional Representative and Senators and ask them to support the Medicare Audiologist Access and Services Act. Supporters may also donate to an advocacy fund of their choosing that is dedicated to advancing the Medicare Audiologist Access and Services Act.

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