Download Minimum Hearing Loss Threshold (MHLT)

Minimum Hearing Loss Threshold (MHLT)
Table of Contents
Minimum Hearing Loss Threshold (MHLT) ...................................................................................... 1
Exemption Criteria to the Minimum Hearing Loss
Threshold
2
Guidelines for the Administration of the Minimum Hearing
Loss Threshold
3
Criterion 1 ................................................................................................................................ 3
Criterion 2 ................................................................................................................................ 4
Other Considerations
5
Monitoring and Compliance
5
The Office Review and Audit .................................................................................................... 5
Documentation and Claiming Requirements ............................................................................ 5
Medicare e-claiming system ..................................................................................................... 5
Manual claiming ....................................................................................................................... 5
Recording 3FAHL of 23.3 dB ................................................................................................... 5
Contacting OHS Audiologists ................................................................................................... 6
References
MHLT Guidelines August 2012
6
Page 1
The Minimum Hearing Loss Threshold is regulated under the Hearing Services (Participants in the
Voucher System) Determination 1997. As of 1 July 2010, clients whose 3 Frequency Average
Hearing Loss is less than or equal to 23 dB in the ear being fitted, cannot proceed to fitting to that
ear; nor can they be provided with an Alternate Listening Device, unless the client meets the
exemption criteria (below).
In this document, a „minimal hearing loss‟ is defined as a 3 Frequency Average Hearing Loss
(measured at 0.5, 1 & 2 kHz) of less than or equal to 23 dB (ie, 3FAHL ≤ 23 dB).
A degree of hearing loss does not on its own predict a need, benefit or outcome with respect to a
fitting. Much depends on the nature of the hearing loss; the configuration of the hearing loss; the
degree of communication difficulties experienced; and on the attitude, motivation and goals of the
individual client.
Not all eligible voucher holders who attend for a hearing assessment are looking to proceed to a
fitting. Some clients with a degree of hearing loss may not want or need a hearing aid.
Consideration of Item 670 (rehabilitation without hearing aids) may be a suitable option for these
clients.
Exemption Criteria to the Minimum Hearing Loss
Threshold
The Office of Hearing Services (the Office) recognises that some clients with a minimal degree of
hearing loss may nonetheless demonstrate a clinical need for, and will benefit from, the provision
of a hearing device. For this reason, a set of criteria for determining exemptions to the threshold
has been established in legislative regulations.
Hearing practitioners must follow these criteria when assessing whether it is appropriate to fit or
refit a client with minimal hearing loss within the context of the Australian Government Hearing
Service Program (the Program). It is anticipated that only a small number of clients with minimal
hearing loss will meet the criteria and proceed to a fitting.
The criteria address significant aspects of rehabilitation and when considered together as a test
battery, they will (a) maximise the likelihood of identifying those clients who are experiencing
serious consequences from their hearing loss; and (b) maximise the chance of a successful
rehabilitation outcome.
All voucher holders are subject to the following two criteria when determining exemptions to the
threshold. Under the first criterion the client must meet at least one of four conditions. Both criteria
must be met for an exemption to apply.
1. One of the following conditions applies:
a) Client has a High Frequency Average Hearing Loss (measured at 2, 3 & 4 kHz) which is equal
to or greater than 40dB (ie, HFAHL ≥40dB.); OR
b) Client has tinnitus, where both the hearing loss and the tinnitus can be addressed through the
use of an approved hearing device; OR
c) Client has a visual impairment that cannot be corrected by treatment, and which reduces the
client‟s ability to see mouth movements; OR
d) Client has previously been fitted with a hearing device under the voucher system, where the
client can demonstrate consistent use of the previously fitted hearing device.
And
2. Client has a positive attitude and is motivated to wear a hearing device, demonstrated
through responses to the Wishes and Needs Tool. The client‟s response to each of the individual
questions on the Wishes and Needs Tool must attract a score of at least 2 on the scale, and the
total score must be 5 or greater.
MHLT Guidelines August 2012
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Guidelines for the Administration of the Minimum
Hearing Loss Threshold
Voucher clients must meet both exemption criteria in order to gain exemption from the Threshold.
In order to proceed to a fitting, clients who meet the exemption criteria must meet the results
required when assessing and fitting a hearing device –as outlined in the Hearing Rehabilitation
Outcomes for Voucher Holders (HROs). The exemption criteria together with the results required in
the HROs address significant aspects of rehabilitation and together will (a) maximise the likelihood
of identifying those clients who are experiencing serious consequences from their hearing loss;
and (b) maximise the chance of a successful rehabilitation outcome.
Both Criterion 1 and Criterion 2 must be met.
Criterion 1
One of the following conditions applies:
a) Client has a High Frequency Average Hearing Loss (measured at 2, 3 & 4 kHz) which is
equal to or greater than 40 dB (ie, HFAHL ≥40dB.); OR
b) Client has tinnitus , where both the hearing loss and the tinnitus can be addressed
through the use of an approved hearing device; OR
c) Client has a visual impairment that cannot be corrected by treatment, and which
reduces the client’s ability to see mouth movements; OR
d) Client has previously been fitted with a device under the voucher system, where the
client can demonstrate consistent use of the previously fitted hearing device.
a) Client has a High Frequency Average Hearing Loss (measured at 2, 3 & 4 kHz) which is
GREATER THAN OR EQUAL TO 40 dB (ie, HFAHL ≥40dB.).
1. Calculate the high-frequency average hearing loss, measured at 2, 3 & 4 kHz (HFAHL).
If the HFAHL is greater than or equal to 40 dB then the client is a potential candidate for
fitting.
2. If the HFAHL is LESS than 40 dB then the client is NOT considered a candidate
for fitting under this criterion.
3. NOTE: Where there is an air-bone gap in the high frequencies, check headphone
placement/collapsing canals before calculating HFAHL.
b) Client has tinnitus, where both the hearing loss and the tinnitus can be addressed
through the use of an approved hearing device. As a condition separate to hearing
impairment, tinnitus cannot be the sole reason to provide hearing aids to eligible clients.
However, an exemption to the MHLT will be granted to clients with a minimal hearing loss
for whom amplification serves to reduce or eliminate severe or constant tinnitus that affects
quality of life. Fitting may proceed where amplification can be shown both to address the
hearing loss and to reduce the tinnitus. The practitioner must be able to show through their
documentation that aiding the client has had successful outcomes for both their hearing
loss and tinnitus relief.
In such cases, it will be necessary to document evidence of the severity of the tinnitus,
using a tool such as the Tinnitus Reaction Questionnaire (TRQ); the Tinnitus Handicap
Inventory (THI); the Assess Your Stress Inventory (eg Hari‟s Stress Inventory); or the
Stress Vulnerability Scale.
c) Client has a visual impairment that cannot be corrected by treatment, and which
reduces the client’s ability to see mouth movements. Erberi describes an 8-9 dB
improvement when clients have access to visual cues. Minimal hearing loss clients with
concurrent vision loss may therefore experience greater communication difficulties than
minimal loss clients with good visual acuity, and are possible candidates for fitting.
MHLT Guidelines August 2012
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In such cases, it will be crucial to document evidence that amplification serves to improve
audibility of speech, as required under the HROs.
Clients with more serious visual impairments should continue to be notified to THE OFFICE
as Complex Clients.
d) Client has previously been fitted with a hearing device under the voucher system,
where the client can demonstrate consistent use of the previously fitted hearing
device.
For clients with minimal hearing loss previously fitted under the Program (with either
hearing aids or an Alternate Listening Device), practitioners must provide evidence that the
client has consistently used a device previously fitted.
Documented evidence of consistent use may come from sources such as:
 hours-of-use information from data logging;
 repeated supply of replacement batteries and on-going minor repairs.
Additionally, evidence of benefit and satisfaction from the use of a listening device may be
provided through responses to self-report outcomes questionnaires such as IOI-HAii or
HAUQ.
And
Criterion 2
Client has a positive attitude and is motivated to wear a hearing device
From 1 July 2010, use of the Wishes and Needs Tool (WANT) is mandatory for all clients with a
3FAHL of less than or equal to 23 dB in any ear who are considered for fitting.
The WANT consists of the two questions as issued by the National Acoustic Laboratories on 1 July
2010. This tool is a client self-report instrument. Clients will answer the two questions, and their
answers will be recorded as part of the client file. Wherever possible, clients should complete these
questions without assistance from the practitioner or others to ensure that the answers reflect the
clients‟ own perspective on attitude and motivation.
There should be no information included on the tool that might lead the client to a particular score.
The WANT should be stored as part of the client file, either physically or electronically.
The tool is simple, quick to apply and easy to score. The questions are intended to be
administered towards the end of the assessment/reassessment appointment.
Dilloniii identified that clients who were motivated were more likely to be successful hearing aid
wearers. In a 2005 survey of clients, analysis of client answers to two questions correlated highly
with device fitting outcomes. Information about clients‟ readiness to accept hearing aids gives
valuable information about fitting candidacy.
Clients who are identified as being unready to accept hearing aids, or whose
responses indicate minimal communication difficulties, should not proceed to
fitting.
The expectation is that practitioners operating under the Program, as in all clinical settings, will use
a range of formal and informal approaches to assess clients‟ attitude and motivation towards
rehabilitation and hearing device fitting.
In addition to the mandatory WANT attitude and motivation may be evaluated using
questionnaires, or by informal questioning during the initial interview/history.
One example of informal questioning is that used by Goldstein and Stephens (1981)iv.
Examples of questionnaires completed by the client prior to the initial appointment include:
 Hearing Handicap Inventory for the Elderly (HHIE)v
MHLT Guidelines August 2012
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
Denver Scale of Communication Function (DSCF)vi
Other Considerations
Asymmetrical Hearing Loss - Practitioners may fit clients with unaidable hearing in the poorer
ear at their own discretion (eg with a CROS device) providing requirements against the Hearing
Rehabilitation Outcomes are met.
When a client has one ear with a 3FAHL (0.5, 1 & 2 kHz) above the 23 dB threshold and one ear
with a 3FAHL equal to or below the 23 dB threshold (the better ear), then each ear needs to be
evaluated independently.
In order to fit the better ear, the exemption and fitting HRO results must be met.
Monitoring and Compliance
Monitoring will include, but not be limited to, client surveys, targeted audits and clinical file reviews.
The Office Review and Audit
Files of all clients with minimal losses (those who are fitted as well as not fitted) will be subject to
the usual The Office review and audit processes. Reviews will focus on file documentation relating
to each of the above considerations as well as the final outcome for clients.
Documentation and Claiming Requirements
Documentation must be kept on file regarding all criteria for each client with a minimal hearing loss
who is considered for device fitting. As with all fittings, claiming should not proceed if fitting has not
achieved its purpose and is therefore unsuccessful.
Medicare e-claiming system
All providers are to enter the client‟s recorded hearing loss into the Medicare e-claiming system.
Providers who are found not to be entering this information into the Medicare e-claiming system
will be targeted for audits conducted on OHS client files to ensure their claiming practices are
meeting their obligations as a service provider.
The Office will take action against providers who claim for a service under the Program for clients
who do not meet the MHLT criteria. This action may include, but is not limited to, recovery of all
funds claimed.
Manual claiming
If a manual claim is required for a client fitted under the MHLT criteria, include the client‟s
audiogram, a signed copy of the WANT tool (in the form as issued by NAL), and if applicable,
documentation showing how the client meets one of the four exemption criteria (i.e. a completed
copy of a tinnitus questionnaire, a letter from a relevant professional documenting a client‟s visual
difficulties, etc).
Recording 3FAHL of 23.3 dB
As the closest whole number to 23.3 dB is 23 dB, it is appropriate to enter the client‟s 3FAHL as 23
dB. When claiming electronically, proceed as per usual and ensure the audiogram on file
corroborates that the client‟s 3FAHLs are actually 23.3 dB. If claiming manually, include
information on the manual claim cover sheet that the client‟s 3FAHL is 23.3 dB and include a copy
of the client‟s most recent audiogram.
MHLT Guidelines August 2012
Page 5
Contacting OHS Audiologists
Practitioners are welcome to contact OHS with enquiries about the content of this document, or to
discuss individual cases. You should note however, that the Office audiologists are unable to grant
any exemptions to the MHLT beyond those which are determined using the criteria outlined above.
References
i.
Erber, NP: Hearing, Vision, Communication and Older People, Clavis Publishing (2002)
ii. Cox RM, Alexander GC (2002) “The International Outcome Inventory for Hearing Aids (IOI-HA):
psychometric properties of the English version.” International Journal of Audiology 41(1): 3035.
iii. Denis Byrne Oration (2008), presented at Audiology Australia Conference, Canberra, 2008
iv. Goldstein and Stephens. Audiological Rehabilitation. Management Model 1, International
Journal of Audiology 1981, 20(5), 432-452
v. Weinstein, BE; Spitzer, JB; Ventry, IM. Test-Retest Reliability of the Hearing Handicap
Inventory for the Elderly. Ear and Hearing Oct 1986, Vol 7, Issue 5
vi. Kaplan, H; Feeley, MA; Brown, J. A modified Denver Scale: Test-Retest Reliability. JARA Vol
XI, 2, Oct 1978
MHLT Guidelines August 2012
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