Download VR Guide on Serving Consumers who are Deaf, Late

GUIDE ON SERVING
INDIVIDUALS WHO ARE DEAF, LATE-DEAFENED,
HARD OF HEARING, OR DEAF-BLIND
Division of Vocational Rehabilitation
Florida Department of Education
Updated December 2011
1
Table of Contents
Introduction
Page
3
Philosophy
3
Population
4
Limitations and General Barriers
4
The Rehabilitation Process
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A. Communicating with Individuals who are Deaf, Late-Deafened, Hard of Hearing, or Deaf-Blind
B. Case Finding & Referral
C. Intake
D. Determination of Eligibility
E. Reports Required for Eligibility or Services
F. Assessment
G. Individualized Plan for Employment (IPE)
H. Counseling and Guidance
I. Physical and Mental Restoration
J. Vocational Training
K. Placement and Follow-up
L. Post-Employment Services
Standards for VR Deaf and Hard of Hearing Services
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A. Interpreter Services for Individuals with Hearing Loss
B. Communication Access to VR Offices
DVR Staff
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A. Professional Staff at DVR Headquarters
B. Local DVR Staff Serving Individuals who are Deaf, Late-Deafened, Hard of Hearing, or Deaf-Blind
Supervision of Rehabilitation Counselors for the Deaf and DVR Unit Staff
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Review of Deaf and Hard of Hearing Services
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Interagency Cooperation
23
2
Appendices
A. Guide on Hearing Loss and Purchase of Hearing Aids
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B. Guidelines for Cochlear Implants (CI)
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State Prior Approval Checklist for CI or BAHA Surgery/Implantation
3
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INTRODUCTION
The Guide on Serving Consumers who are Deaf, Late-Deafened, Hard of Hearing, or Deaf-Blind is based
on previous editions of the Florida Model State Plan for Deaf and Hard of Hearing). This revision is made
necessary due to new updates found in the April 2008 edition of the national Model State Plan for
Rehabilitation of Persons who are Deaf, Deaf-Blind, Hard of Hearing or Late Deafened (MSP). A copy of
the MSP can be seen on the VRI-Net (VR Intranet). Or, you can see MSP via internet at:
[http://www.hawaiivr.org/forms/mspdeaf.pdf ]
The purpose of this Guide is to enhance the effectiveness of Florida's Division of Vocational Rehabilitation
(DVR) as it relates to serving individuals with hearing loss. This document is designed to supplement other
resources on VRI-Net (VR Intranet) and clarify areas in the provision of rehabilitation services to individuals
who are deaf, late-deafened, hard of hearing, or deaf-blind, and not intended to amend, substitute, or
change in any way the State Plan of DVR. While attempts are made to secure more recent information,
there is a scarcity of research in this field.
DVR recognizes the task of meeting the vocational needs of this population. To the fullest possible extent,
the agency will assure that every working age individual who is deaf, late-deafened, hard-of-hearing, or
deaf-blind, unemployed or underemployed will be provided the opportunity to be considered for vocational
rehabilitation (VR) services.
This Guide may not represent an ideal or the best possible way to serve individuals with hearing loss, but
provides minimum standards to aid counselors and staff working with this population.
PHILOSOPHY
DVR, through its services to individuals who are deaf, late-deafened, hard of hearing, or deaf-blind
supports a philosophy that specific procedures and practices are necessary to fulfill the rehabilitation needs
of this population. The basic key considerations need to be recognized when providing services to every
eligible individual who are deaf, late-deafened, hard-of-hearing, or deaf-blind:

They have a right to be provided services necessary to achieve the degree of independence that
reflects his/her native abilities.

If unemployed, they should be considered for VR services until evaluation and diagnosis prove
otherwise.

If grossly underemployed, they may be considered candidates for VR services unless otherwise
indicated through case study, including review of community resources and current economic
conditions.

The DVR will assist and train its staff to ensure that they understand the unique problems of this
population and help them develop skills to communicate with this population.
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The DVR will emphasize outreach efforts, utilize existing resources, develop needed programs,
and provide appropriate opportunities for this population as they go through the rehabilitation
process.

The DVR will help prepare, support or train individuals by improving their mental, physical, social,
psychological and economic status so they can achieve their appropriate vocational objectives.
POPULATION
According to the National Institute on Deafness and Other Communication Disorders (NIDCD),
approximately 17 percent (36 million) of American Adults report some degree of hearing loss in 2008
(http://www.nidcd.nih.gov/health/statistics/Pages/quick.aspx).
LIMITATIONS AND GENERAL BARRIERS
Individuals who are Deaf
In general, individuals who are deaf face significant barriers that affect their own self-sufficient functioning.
Many individuals who are deaf also lack extensive experience in interpersonal relations that are critical to
development of their self-identity and social confidence, both at home and at work.
Review of studies conducted in the past twenty years characterized individuals who are deaf and working,
as follows (Boone & Long, 1988):

Individuals who are deaf and working are generally found in unskilled, semiskilled or otherwise
manual occupations. There is very little representation of this population in professional and
administrative occupations.

These jobs are frequently characterized by low job security and little opportunity for advancement
beyond entry-level.

Many of these jobs pay low wages. Although reliable and stable, the average individual who is
deaf and working earns only 72 percent as much as the average individual with normal hearing in
the labor force. Salaries of nonwhite individuals who are deaf and working are even lower.

Many of the occupations in which deaf individuals are clustered are occupations, which are either
declining in demand or projected to undergo only minimal growth. Advanced technology is rapidly
replacing many of these occupations.

Very few individuals who are deaf are employed in rapidly growing occupational clusters.

Females who are deaf and nonwhite fare less well in obtaining employment. Although, males who
are deaf are employed at a rate comparable in general to, or slightly above, males with normal
hearing, females who are deaf suffer 50 percent more unemployment in general than those who
are nonwhite and far worse than the males who are deaf and white.
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Prevocational individuals who are deaf have a greater difficulty obtaining employment. The
average educational attainment (years attended school) falls below that of the general population,
further handicapping their ability to compete. Obstacles surrounding communication are important
factors related to the earnings and occupational attainment of these workers.

A significant proportion of individuals who are deaf and working exhibit personal and/or work
adjustment deficits, which jeopardize their obtaining and/or retaining employment. Approximately
30 to 50 percent of the low-achieving rehabilitation population presents other disabilities in addition
to deafness.
Individuals who are Late-Deafened
Individuals who are late-deafened adults are those who were not born deaf, but became deaf after they
developed language skills. They cannot understand speech without visual cues, and thus cannot rely on
their hearing as a means of receptive communication. Instead, individuals who are late-deafened must
primarily depend on some visual mode of receptive communication, such as:
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lip reading,
sign language, or
text reading.
Their deafness may have been the result of heredity, accident, illness, drugs, surgery or “causes unknown.”
Their hearing loss may have occurred suddenly or very slowly over a period of years. Most importantly,
however, regardless of the cause of rapidity of their hearing loss, all individuals who are late-deafened
share the cultural experience of having been raised in the hearing community, and having “become” deaf
rather than having been “born” deaf. (Miller, 1998) It is estimated that 75% of individuals who are latedeafened became deaf after the age of 19 (Schein & Delk, 1974).
According to a focus group study by Goulder (1998), individuals who were deafened in early adulthood and
in pre-career stage, expressed the most concern about:
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loss of social relationships,
how to obtain advanced education, and/or
finding appropriate employment.
Individuals who were in the mid-life age group, expressed concern over work issues such as:
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limited advancement opportunities,
job performance, retention, and
possible job loss due to their deafness.
Issues of technological assistance on the job were discussed by the individuals with major concerns
identified as:
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the use of the telephone,
relationships with supervisors, and
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general communication issues with other employees.
Participants who have higher educational levels and years of experience in the work place prior to
becoming deafened appear to have better job security when compared to younger individuals who are
deafened as adults and facing training issues and lacking job experience. However, even the welleducated and experienced individuals who work expressed frustration regarding employment mobility and
retraining in the work place. Individuals who are late-deafened in this study predominantly relied on speech
as their primary mode of communication.
Individuals who are Deaf-Blind
Individuals who are deaf-blind vary significantly depending on etiology, age of onset, degree of vision and
hearing loss, communication preference, educational background, and life experience. Very few individuals
who are Deaf-Blind have complete loss in both senses. Their communication preferences will depend
greatly on which sense they loose first, hearing or vision. Individuals who lose their hearing first will most
likely communicate using tactile sign or close vision sign and will require the use of an interpreter.
Individuals who lose their vision first will most likely utilize assistive listening devices or devices that provide
Braille assistance.
Support Service Providers (SSP) may be used with any individual who is deaf-blind to assist them in
developing independence, and both adjusting to and navigating in their environment. Currently, there is no
program in Florida to certify and pay for an SSP. The individual who is deaf-blind may bring their own SSP
to the meeting.
DVR currently has a cooperative agreement with the Division of Blind Services (DBS)
[http://dbs.myflorida.com/] that outlines procedures on serving individuals who are deaf-blind. If an
individual is deaf-blind, the supervisors of the respective divisions shall jointly assign the case to the most
appropriate DVR counselor and/or DBS specialist. A joint staffing of counselors of both divisions will be
held for each case to determine whether it is a dual case involving both divisions at the same time, or
whether one division should take the full responsibility of serving the individual while the other will provide
consultation as needed. Both agencies may receive credit for a successful closure if they dually serve the
individual with a successful job outcome. For more details on these procedures, go to VRI-Net (VR
Intranet) to see the latest version of the DBS/DVR cooperative agreement.
Individuals who are Hard of Hearing
Most individuals who are hard-of-hearing do not share the same communication, cultural, and social
identities of many individuals who are deaf. The individual who is hard of-hearing faces problems such as:
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difficulty understanding speech,
denial,
lack of understanding by family, friends, and peers,
rejection; isolation, and
ultimately, withdrawal.
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They may suspect that individuals reject them because they are different or too much trouble to talk with.
Some individuals including family members may label such problems as:
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laziness,
being a snob,
retardation,
mental problems,
bad attitude, or
spitefulness.
This lack of sensitivity by others can contribute significantly to their negative experience about themselves.
Often, the individual who is hard-of-hearing:
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Struggles with trying to identify which community they belong - hearing or deaf;
Does not usually learn sign language, so their involvement with those who are deaf is rare;
May experience complications on the job similar to their personal situations;
May have difficulties maintaining their jobs; and
Like those who are deaf, may find accommodations and devices for hearing loss to be quite
expensive.
Hearing loss, changes in self-image, and frustrations with communication may affect job performance
and perceptions by employers and coworkers.
In addition to perhaps needing hearing aids, telecommunication devices, captioning decoders, and visual
alert systems, they may have to consider surgery, ongoing speech therapy, assistive listening devices,
extensive use of transportation for face-to-face communication, and/or ongoing auditory training. Coping
strategies have been shown to play a major role in adjustment to hearing loss by the individual who is
hard-of-hearing.
Socio-psychological interventions, surgical procedures, auditory and/or speech training, and assistive
listening devices are a few of the services, which may enable the individual who is hard of hearing to
succeed in our society as a productive employee.
Individuals who are Deaf and Low-Functioning
Within this larger population of individuals who are deaf and hard of hearing is a group whose skills and
competencies are considered to be inadequate to achieve employment or independent living goals. These
individuals have been referred to terms such as:
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“low-functioning deaf individuals,”
“underachieving,”
“severely disabled,”
“minimal language skilled,”
“multiply handicapped,” and
“traditionally underserved.”
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The term “low-functioning deaf,” which sometimes also included individuals who are hard of hearing has
been used since the late 1970’s to describe this group (Dew, 1999). A survey research study conducted by
Long, Long and Ouelette in 1993 (Dew, 1999) identified a number of risk factors often associated with
individuals who are deaf and hard of hearing who have been identified as Low-Functioning Deaf (LFD).
These factors include:
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low socioeconomic status,
incorrect diagnosis,
being foreign born,
being a member of a minority
community, or from an environment
where the spoken language in the home
is not English,
lack of access to appropriate education,
lack of family support,
substance abuse,
secondary disabilities,
discrimination, and
residence in a very small rural or low
economic urban setting.
As a consequence of these risk factors and the interactive effects of these factors with each other and with
hearing loss, adults who are identified as LFD are more likely to experience limited communication abilities,
difficulty maintaining employment, poor social and emotional skills, and are assumed to be unable to live
independently without transitional (sometimes on-going) assistance or support. These individuals are
considered among the most significantly disabled in the rehabilitation system.
Individuals who are deaf and are eventually determined to be “low-functioning” are identified because of a
diagnosed secondary disability or because of problems in behavior, academic achievement, language use,
development of independent living skills, employment, or some other major life functioning with no known
etiology. For some individuals who are LFD, identification is based on standard assessment methods, which
will diagnose a second disability, such as blindness, developmental disability, or other conditions. For others
who have experienced some form of language, social, or educational deprivation, the identification may be
based upon performance measures. (Dew, 1999)
RSA research and demonstration projects over the past several decades (1963-1998) have agreed on six
characteristics that seem to describe individuals who are LFD (Dew, 1999):

Inadequate communication skills due to inadequate education and limited family support.
Presenting poor skills in interpersonal and social communication interactions, many of these
individuals experience difficulty expressing themselves and understanding others, whether through
sign language, speech and speech reading, or reading and writing.

Vocational deficiencies due to inadequate educational training experiences during the
developmental years and changes in personal and work situations during adulthood. Presenting
an underdeveloped image of self as a worker, many exhibit a lack of basic work attitudes and work
habits as well as a lack of job skills and/or work skills.

Deficiencies in behavioral, emotional, and social adjustment. Presenting a poorly developed sense
of autonomy, many exhibit low self-esteem, have a low frustration tolerance, and have problems of
impulse control that may lead to mistrust of others and pose a danger to self and others. Because
they experience difficulty in normal social interactions, many are avoided or rejected either
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because of socially unacceptable behaviors or because of societal attitudes and discriminatory
actions toward them.

Independent living skills deficiencies. Many of these individuals experience difficulty living
independently, lack basic money management skills, lack personal hygiene skills, cannot manage
use of free time, do not know how to access health care or maintain proper nutrition, and have poor
parenting skills.
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Educational and transitional deficiencies. Most read at or below a fourth-grade level and have
been poorly served by the educational system, are frequently misdiagnosed and misplaced, lack a
supportive home environment, are often discouraged in school and drop out, and are not prepared
for post-school life and work. Approximately 60% of students who are deaf and leaving high school
cannot read at the fourth-grade level.

Health, mental, and physical limitations. Many have no secondary physical disabilities but a large
number have two, three, and sometimes more disabilities in addition to that of deafness. In fact,
30% of students who are deaf and leaving high school had an educationally significant additional
disability. These secondary disabilities range from organic brain dysfunction to visual deficits.
These problems are further compounded in many instances by a lack of knowledge on how to
access health care and/or self-care.
References
Boone, S. and Long, G. (Eds.). (1988). Enhancing the Employability of Deaf Persons: Model Interventions.
Springfield, Illinois: Charles C. Thomas Publisher.
Dew, D. (1999). Serving Individuals Who are Low-Functioning Deaf: 25th Institute on Rehabilitation Issues. The
George Washington University Regional Rehabilitation Continuing Education Program: Washington, D.C.
Goulder, T.J. (1998). Journey through Late-Deafness. In The Challenge of Tomorrow by Carolyn Piper
and Douglas Watson, Eds. University of Arkansas Rehabilitation Research and Training Center
for Persons who are Deaf or Hard of Hearing: Little Rock, Arkansas.
Miller, Roy. (1998). A Brief History of ALDA. In ALDA Best 1987-1996 by David Coco, Mark Dessert,
Marilyn Howe, and Douglas Watson, Eds. University of Arkansas Rehabilitation Research and
Training Center for Persons who are Deaf or Hard of Hearing: Little Rock, Arkansas.
Schein, J. & Delk, M. (1974). The Deaf Population of the United States. NAD: Silver Spring, Maryland.
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THE REHABILITATION PROCESS
A.
Communicating with Individuals who are Deaf, Late-Deafened, Hard-of-Hearing, or Deaf-Blind
The key to successful rehabilitation is the full participation of individuals who are deaf, late-deafened, hard
of hearing or deaf-blind. Full and equal participation throughout the rehabilitation process includes a
provision of timely and effective communication (auxiliary aids and services) per Section 504 of the
Rehabilitation Act of 1973 and Title II of the Americans with Disabilities Act. Care should be taken in each
step of the rehabilitation process so that these individuals are involved and understand both their and the
agency's responsibilities.
The DVR staff is expected to maintain full, effective, and clear communication with all individuals who have
hearing loss. The DVR staff shall inquire and honor the individual’s preference for auxiliary aid or service in
accordance to Section 504 of the Rehabilitation Act of 1973 and Title II of the Americans with Disabilities
Act.
The DVR counselor shall also document in case notes what auxiliary aid or service was provided during
each internal and/or external appointment, including the initial interview in which the rights and
responsibilities are to be reviewed with the individual. If the preferred auxiliary aid or service is not
provided, the DVR counselor shall document the reasons and state whether or not an alternate auxiliary aid
or service was provided.
The DVR staff shall explain and provide contact information regarding the DVR Ombudsman office. This
office is available to resolve any concerns individuals may have with DVR regarding auxiliary aids and
services, including scheduling difficulties or not understanding the interpreter.
Individuals who are Deaf
Individuals who are deaf are visually oriented while depending on either manual or oral (speech and lip
reading) methods of communication. This underscores the critical need for visible expression to be
congruent with what is being communicated. The individual who is deaf must always leave the service
contact knowing clearly the time and place of the next appointment (e.g. what happens next?).
Personnel who regularly meet individuals who are deaf should develop effective manual skills, primarily the
use of American Sign Language (ASL). Rehabilitation Counselors for the Deaf (RCDs), technicians,
support staff and others coming in contact with these consumers should become proficient in expressive
and receptive manual communication. Whenever an individual requests a sign-language interpreter, the
DVR staff will determine the individual’s preferred mode and level of communication. DVR will utilize either
a VR staff or qualified vendor sign-language interpreter to ensure timely and effective communication.
According to the Americans with Disabilities Act (ADA), the qualified interpreter shall convey
communication effectively, accurately, and impartially, both receptively and expressively, including the
ability to convey any specialized vocabulary (28 CFR Part 35). Rehabilitation staff should not take for
granted the skill and ability of interpreters. Evidence of interpreter credentials should be verified through
DVR Vendor Certification Unit.
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The RCD and the individual who is deaf have the right to request or reject an interpreter. Interpreters
should be used whenever rehabilitation staff cannot adequately communicate with individuals who are deaf.
Additional information on interpreters can be found on Page 19 of this guide (“Interpreter Services for
Individuals with Hearing Loss” under “Standards for VR Deaf and Hard of Hearing Services”) and in a
separate DVR Manual on Interpreter Services for Individuals with Hearing Loss. Further, the DVR staff
should not ask customers to bring their family, friend, or advocate as an interpreter. If the individual
decides to bring their own interpreter, the DVR counselor should explain why this may not be a good idea.
If the individual is still adamant on bringing their own interpreter, the DVR counselor should document this
in the case notes.
For individuals who rely on oral communication, the potential for misunderstanding increases. Therefore,
oral interpreters may help.
Individuals who are Late-Deafened or Hard of Hearing
Communication needs of individuals who are late-deafened or hard of hearing and those who are deaf may
differ. While individuals who are late-deafened or hard of hearing face difficulty understanding speech, few
use sign language.
These individuals may require face-to-face communication involving lip-reading and/or intensive listening
with use of hearing aids or assistive listening devices (for example, personal FM system). There may be a
need to repeat messages to assure that everything is being understood. Written notes can be helpful as
well.
B.
Case Finding and Referral
Case finding and referral require special efforts on the part of the RCD to bring individuals who are deaf,
late-deafened, hard of hearing, or deaf-blind into the rehabilitation process.
Referral sources may need to be cautioned not to determine "individual eligibility". They should be
encouraged to refer individuals who are deaf, late-deafened, hard of hearing, or deaf-blind to VR and leave
eligibility determination to the RCD. Qualified staff and good services help build referrals.
Information about Vocational Rehabilitation (VR) services circulates quickly through the deaf community
and among those who are late-deafened, hard of hearing, or deaf-blind. When individuals who are
hearing-impaired are served well by VR, referrals tend to increase. Principal referral sources of individuals
who are deaf, late-deafened, hard of hearing, or deaf-blind may include the following:
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Public or residential day schools
State associations
Self-help groups (hard of hearing)
Local clubs
Parent and teacher groups
Organizations and facilities serving
hearing-impaired people
Special education programs
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State Hospitals
Audiologists
Otologists and speech pathologists
Hearing-aid dealers
Speech and hearing centers
Deaf service centers
Rehabilitation centers
Centers for independent living


One-stop centers
Representatives of employment, welfare,
and social security offices
To ensure successful school-to-work transitions, DVR may work with:
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secondary and post-secondary schools,
parents,
sheltered workshops,
rehabilitation facilities,
independent living centers, and/or
service providers to adequately prepare individuals who are deaf, late-deafened, hard of hearing,
or deaf-blind for employment and independent living.
It is ideal to initiate contacts during junior and senior years in high school. For adults, the challenge for DVR is
to train them for new occupations due to their difficulties in getting job promotions, loss of jobs, unemployment
or underemployment.
Important considerations in establishing effective outreach services are as follows:
1. Individuals who are deaf frequently attend established events where there is a greater
concentration of other individuals who are deaf. Unlike individuals who are deaf, those who are
late-deafened and hard of hearing individuals may only get together in announced local group
meetings such as Hearing Loss Association of America (HLAA).
2. Understanding unique needs and problems of individuals who are deaf, late-deafened, hard of
hearing, or deaf-blind requires extra time, willingness and committed personnel.
3. The ability of rehabilitation personnel to effectively communicate with individuals who are deaf,
late-deafened, hard of hearing, or deaf-blind is critical.
4. Letter writing to individuals who are deaf is generally ineffective as an outreach method. Every
effort should be made to communicate directly with the individual who is deaf throughout the
rehabilitation process. It is preferable to use video phones and video relay services instead of
using written communication or Teletypewriters for the Deaf (TTY).
C. Intake
The intake process is a crucial stage in which many individuals who are deaf, late-deafened, hard of hearing, or
deaf-blind are lost because of the lack of meaningful communication. This is usually when the individual's role
in the VR process, planning for services, and the individual's rights (Agreement of Understanding) are clearly
explained. Postponement of certain explanations may be appropriate until rapport has been established;
otherwise, the individual (applicant/individual) may become discouraged by the complex discussion and fail to
return. Meaningful communication and rapport require high level skills in listening, attending and responding as
well as demonstrating empathy, understanding, congruency and respect.
Providing clear "written instructions" with reference to the next appointment along with expectations may be
helpful. Interpreters or assistive devices should be available upon request from the individual. Such
considerations are especially important in the development of the Individualized Plan for Employment (IPE).
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D. Determination of Eligibility
Establishing eligibility for services is a critical legal step in the VR process. Since functional limitation resulting
from a hearing loss may be a substantial impediment to employment, individuals who are diagnosed as deaf,
significantly disabled hard of hearing or deaf-blind are likely to be eligible for services provided their evaluation
shows potential for employment. Eligibility for VR services is based upon three criteria:
1. The individual has a physical or mental impairment;
2. Which constitutes or results in a substantial impediment to employment, and can benefit in terms of an
employment outcome from vocational rehabilitation; and
3. Requires vocational rehabilitation services to prepare for, secure, retain, or regain employment.
Physical or mental disability means a condition that limits, contributes to and if not corrected will probably
result in limiting a person's activities or functioning.
A substantial impediment to employment means that a physical or mental disability interferes with the
individual’s ability to work and prevents the individual from obtaining and retaining employment. In certain
situations where an individual is clearly under-employed, consideration should be given to upgrading to
appropriate levels.
Employment outcome refers to the counselor's determination that the provision of VR services will enable the
individual to become employed in a job commensurate with abilities. It can also refer to self-employed status
in such areas where payment is in kind rather than cash (homemaking, family work, sheltered employment, or
other gainful work).
E. Reports Required for Eligibility or Services
All current records need to be obtained. General Medical Examination (GME) is no longer required but may
be obtained if necessary. An audiological evaluation must be arranged for every individual applicant who is
deaf, late-deafened, hard-of-hearing, or deaf-blind if no recent records are available. In situations of
suspected ear diseases, an otolaryngological report may also be required.
The audiological and/or outolaryngological reports must be the primary source of evidence to substantiate a
hearing loss. The audiological evaluation should be performed by a certified or licensed audiologist. The
audiological report will indicate the type and extent of hearing loss, and the potential for assisting an individual
through the use of a hearing aid. When amplification is recommended, the report generally indicates the
following: ear to be fitted, type of hearing aid, specific characteristics of the aid related to the individual's
needs, individual's attitude toward amplification, indication of trial period and evidence of hearing aid
orientation given to the individual. (See Appendix A)
The otolaryngological report will indicate the condition of the ear, quantitative estimate of the degree of hearing
loss, presence or absence of ear disease, etiology of the condition, prognosis and recommendations for
medical treatment, surgery or amplification.
There are three basic types of hearing losses: conductive, sensorineural and mixed. The type of hearing loss
suggests to a large extent the rehabilitation services that may be necessary. Conductive losses usually
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suggest two alternatives: (1) the correction of hearing disorder through medical treatment or (2) increasing the
loudness of sound through amplification. Some sensorineural losses can be helped through amplification.
One important aspect of diagnosis in hearing-impaired cases is often neglected. This is the visual examination
(ophthalmological evaluation). In cases of congenital deafness, a visual exam is required to rule out the
possibility of retinitis pigmentosa (RP), a disease that generally results in deaf-blindness.
In some cases, consideration should be given to the need for speech evaluation by a certified speech
pathologist. Speech reception and speech discrimination scores are important in predicting rehabilitation
outcome. Speech audiometry information should be an integral part of the evaluation in determining the
appropriateness of auditory training, lipreading instruction and hearing aid selection and use.
It is important for the counselor to be sensitive to how individuals who are deaf feel about audiological
evaluations. Some individual applicants who are deaf may resent and/or resist the requirements for
evaluations of their ears since their hearing loss is chronic and further decline in hearing levels is seen as
having no practical consequence. Available information from other agencies and school records may be
utilized to save time and to avoid unnecessary testing.
F. Assessment
A number of individuals who are deaf, late-deafened, hard of hearing, or deaf-blind may, in addition to their
hearing loss, have other physical and mental disabilities. Appropriate assessment should be utilized for those
individual applicants who are suspected of having other limitations or disabilities. A complete educational,
social, psychological and vocational assessment is often necessary in determining their eligibility as well as
rehabilitation potential.
The following factors are important in considering assessment procedures:
1. Functional illiteracy is evident among many individuals who are either prelingually or prevocationally deaf.
It is important to understand however, that minimal language ability is not an indicator of innate
intelligence. Educational achievement among individuals who are deaf is usually not commensurate with
their schooling.
Another significant factor is whether the individual was educated in a public school class (mainstreaming),
a special education class for students who are hearing-impaired, or in a residential school for the deaf.
Language deficiencies in an individual who is deaf are usually reflected in their speech, writing style,
reading comprehension, vocabulary and syntax. Such deficiencies should not be confused with potential
in other areas (psychological, social or vocational). Standardized achievement test results should be used
only as general indicators of this consumer’s overall educational performance and not as a strict measure
of achievement.
2. Psychological assessments may be considered for some individuals who are deaf, late-deafened, hard of
hearing, or deaf-blind. Important factors which need to be taken into account are:
a. The psychological tests/instrument must be appropriate for individuals who are prelingually or
prevocationally deaf such as performance batteries using norms developed for this population.
16
b. Group testing of individuals who are deaf and severely hard of hearing should be utilized only as a
last resort and as a screening technique.
c. Some tests administered by professionals with limited understanding in sociopsychological
dynamics of hearing loss have resulted in a misdiagnosis of mental illness, mental retardation or
behavioral disorders.
3. Most commonly used vocational assessment procedures have not been validated, standardized and
normed with individuals who are deaf. The work sample approach, however, is probably one of the best
evaluation tools for assessing the vocational potential and may, in some programs, appropriately be used
with these individuals.
In general, psychological and vocational scores for individuals who are deaf and hard-of-hearing are not
precise measurements but can be helpful if used with behavioral observations, experience, situational
assessments and on the job training to provide a more accurate appraisal of vocational potential. A team
approach involving RCD, individuals who are deaf, late-deafened, hard of hearing, or deaf-blind, and
vocational evaluation staff is encouraged in developing possible vocational objectives.
G. Individualized Plan for Employment (IPE)
Initiation and participation in the development of an IPE requires mutual involvement of both the consumer
who is deaf, late-deafened, hard of hearing, or deaf-blind and the VR counselor. A clear understanding of
objectives that lead to the vocational goal is paramount to success of the program.
H. Counseling and Guidance
Counseling and Guidance is the core component of the rehabilitation process provided by the VR
counselor to the individual who is deaf, late-deafened, hard of hearing, or deaf-blind. Successful
counseling involves understanding, trust, and clear communication between the individual and the
counselor.
It is important for the counselor to acknowledge that many individuals who are deaf frequently identify
themselves with American Sign Language and its Deaf culture. Other individuals who are late-deafened
or hard of hearing may rely on use of speech along with necessary modifications such as changes in
lighting, assistive listening devices, and direct (face-to-face) communication. In respect to unique needs of
these individuals, effective communication contributes to the success of counseling.
I. Physical and Mental Restoration
Surgery to restore or improve hearing may be considered, including cochlear implants, whenever there is a
reasonable expectation of a successful outcome, which a hearing aid alone cannot produce. Success can
depend on a number of factors including age of onset of loss, type of loss, severity of condition, and
adjustment to loss. However, the provision of hearing aids (amplification) may be ideal if surgery is not
recommended or is refused by the individual.
Hearing aids shall be considered when there is evidence that the amplification provided by the aid will
contribute to the individual's vocational adjustment (e.g. effective communication) and/or safety on the job
17
(environmental sound awareness). The hearing aid, unlike eyeglasses, does not restore normal hearing
function in the same way eyeglasses do to vision.
It is important for the individual to know that the hearing aid will not restore normal hearing but will only amplify
sounds. Examination by an otolaryngologist, otologist, and/or an audiologist prior to purchasing a hearing aid
is necessary to obtain maximum benefits. Regular (analog) hearing aids have been the ones most prescribed
in the past but they are scheduled to be phased out of production. Digital or programmable aids will be
considered for those who need these devices. (See Appendix A for guidance on the purchase of hearing
aids.)
Hearing aids cannot be provided as a stand alone service. It is important that the individual also receive
guidance and counseling in regard to adjusting to living with hearing loss and how to be successful in utilizing
hearing aids.
Cochlear Implants may be appropriate for individuals who have acquired good speech, lost all of their
available residual hearing in later years, and cannot benefit from hearing aids – either analog or digital ones.
Candidates for cochlear implant must undergo extensive evaluations by specialists first in order to determine
whether or not they are qualified to receive cochlear implants.
Efforts must be made to first secure funding from private insurers. If none is available, VR may cover most, if
not all, of the costs. A prior approval from the state office is required. There are separate guidelines on
securing prior approval for cochlear implants (See Appendix B).
Assistive Devices should be considered and obtained, as appropriate, to enable individuals to become
successfully placed and employed. The Rehabilitation Act Amendments of 1986 emphasize the importance of
rehabilitation engineering and adaptive technology; thus, more assistive devices are made available on the
market to accommodate individual needs of individuals who are deaf, late-deafened, hard of hearing, or deafblind.
The available assistive devices include, but are not limited to, FM, infra-red, audio loop, amplifiers, and
TTY/TDD (Telecommunications Devices for the Deaf). As for the cochlear implants, extensive evaluation and
prior approval from the State Office are required.
J. Vocational Training
Training services for individuals who are deaf, late-deafened, hard of hearing, or deaf-blind cover a broad
spectrum of possibilities, which may include unskilled, technical and professional areas. A thorough
evaluation of specific needs and/or training potential should be developed for each individual who is deaf, latedeafened, hard of hearing, or deaf-blind. Some individuals who have hearing loss may require basic
education including independent living skills prior to entering training. In some programs, basic education can
be accomplished concurrently with training.
Training individuals who are deaf and deaf-blind usually requires a longer period of time compared with other
individuals with disabilities including those who are late-deafened or hard of hearing. The unique needs,
primarily related to communication, require more individual attention during the training period.
18
Post-secondary educational institutions can be considered for those who have demonstrated a greater
potential for success in pursuing higher degrees. Many individuals who are deaf do attend either Gallaudet
University or National Technical Institute for the Deaf (NTID) due to their excellent accommodations for
students who are deaf, late-deafened, hard of hearing, or deaf-blind. However, it is more practical to
encourage individuals with questionable maturity and academic readiness to first attend local community
colleges to determine whether or not they have the potential to attend an out-of-state college or university.
Gallaudet University and NTID, being out-of-state institutions, require prior approval from the Area Office, not
the State Office, as indicated in the Operational Policies and Procedures for DVR Counselors (Counselor
Policy Manual) and the Policy Manual for Vocational Rehabilitation Privatization Initiatives, as appropriate. At
issue with local community colleges is the availability and provision of auxiliary aids such as interpreting
services, assistive listening devices, and CART (communication access real-time captioning). The
Cooperative Agreements between DVR, Department of Education (DOE), Division of Blind Services (DBS),
and both State University and Community College Systems provide guidelines on the responsibility of
providing and paying for auxiliary aids.
The fact that the individual who is deaf, late-deafened, hard of hearing or deaf-blind is already employed does
not mean that training services should be denied. The individual's vocational potential, motivation and
maturity should be considered along with other factors that may indicate that an "under-employed" individual
with hearing loss would benefit from training commensurate with vocational potential.
Maintaining effective communication between the VR counselor and the training institution/representative is of
major importance. The need for other support services such as remedial classroom instruction, interpreting
(oral or sign-language), tutoring, assistive listening devices, and/or note-taking services may be necessary to
enable individuals who are deaf, late-deafened, hard of hearing, or deaf-blind to successfully complete postsecondary training.
K. Placement and Follow Up
The following factors are important and relevant to placing individuals who are deaf, late-deafened, hard of
hearing, or deaf-blind into employment:
1. The VR counselor should develop and maintain regular contacts with employers that express an
interest in hiring individuals who are deaf, late-deafened, hard of hearing, or deaf-blind. Job
opportunities for individuals who are deaf, late-deafened, hard of hearing, or deaf-blind will improve
whenever employers are invited to participate in workshops, seminars and conferences on working with
individuals who are hearing-impaired.
2. The VR counselor should consider accompanying the individual to job sites to familiarize employers
with unique talents as well as possible accommodations. This smoothes the way for the individual and
opens possibilities for others to follow.
3. The first days following placement are often difficult. New work relationships must be formed with coworkers and supervisors. New communication patterns are being established, new transportation
routes are being learned, and new work skills are being acquired and maintained.
4. VR counselors and Staff Interpreters or hiring of qualified interpreter vendors may be very helpful
during the early phase of job placement. They can provide tips to co-workers and the supervisor on
effective communication practices with individuals who are deaf. They can also assist in job
orientation. In addition, it will be helpful for the staff to present an awareness program to co-workers
19
5.
6.
7.
8.
9.
and supervisors to deal with these issues including any misconceptions the employees may have
regarding hearing loss.
Completing job applications may reveal language difficulties of individuals who are deaf. Many
individuals who are deaf are reluctant to expose their weaknesses in reading and writing. The VR
counselor may want to encourage these individuals to consider job-seeking skills training in order to
boost their confidence.
The job interview can be a very traumatic experience for an individual who is deaf. The use of a Staff
Interpreter or hiring of a qualified interpreter vendor for the job interview is strongly recommended and
may also be very helpful during the initial phases of employment when the individual is hired.
Many job responsibilities are learned through casual conversations with co-workers so the individuals
who are deaf, late-deafened, hard of hearing, or deaf-blind may be at a disadvantage. For these
individuals, effective and thorough job orientation is a necessity. The rules, responsibilities, work
hours, pay, job benefits, and supervisor’s expectations must be clearly explained to individuals who
have hearing loss.
An alternative to permanent placement is "on-the-job training" which may be helpful in overcoming
resistance by the employer in hiring of individuals who are deaf, late-deafened, hard of hearing, or
deaf-blind.
Close follow-up services by the VR counselor are vital to a successful placement outcome. Federal
regulations require satisfactory employment for at least 90 days before a "26" closure can be claimed,
however literature recommends that a period of 120 or more days is an ideal time to follow-up before
closing the case.
L. Post-employment Services
Post-employment services for individuals who are deaf, late-deafened, hard of hearing, or deaf-blind may be
considered. Additional services that prove necessary to preserve a job and independent living after case
closure should be provided as authorized by law and regulation. Individuals who are deaf and working may
occasionally be provided with interpreters if it can be shown that this service is essential to keeping their jobs.
With the passage of 1986 Amendment to the Rehabilitation Act of 1973, individuals who are deaf may benefit
from supported employment services. The supported employment program is defined as competitive work in
an integrated work setting, with ongoing support services. This program is ideal for individuals with significant
disabilities, for whom competitive employment has not traditionally occurred, or has been interrupted or
intermittent as a result of severe disability, or transitional employment for individuals with chronic mental
illness.
The supported employment services emphasize critical communication and elimination of isolation on the job.
Job coaches may be provided. Generally, VR covers Phase One services (short-term) while another entity
such as Developmental Services (DS), Substance Abuse and Mental Health (ADM), or contracted agency
covers Phase II services of supported employment (long-term). VR cannot provide Phase I services if Phase
II providers are not available. However, in Florida, individuals who are deaf are not eligible for supported
employment services unless they have additional disabilities [e.g. developmental (DS), mental health (ADM)].
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STANDARDS FOR VR DEAF AND HARD OF HEARING SERVICES
A.
Interpreter Services for Individuals with Hearing Loss
Every state is expected to have a program policy on interpreter services. This policy complies with Title V,
Section 504 of Rehabilitation Act of 1973, as amended by Public Law 99-506 and 100-630, 29 CFR,
Sections 32-33, and Title II of the Americans with Disabilities Act of 1990 (42 U.S.C.). Interpreter Services
are covered in the Operational Policies and Procedures for DVR Counselors (Counselor Policy Manual) or
the Policy Manual for Vocational Rehabilitation Privatization Initiatives, as appropriate.
The Latest DVR “Manual on Interpreting Services for Individuals with Hearing Loss” includes the legal and
background information, purpose, procedures and expectations. This manual also discusses the use of
interpreter services throughout the VR process, best practices, working with interpreters, and hiring
interpreter vendors.
Interpreter credentials must be verified before authorizing interpreter services - national interpreter
certifications (Registry of Interpreters for the Deaf and quality assurance (QA) screening levels through the
Florida Registry of Interpreters for the Deaf. The DVR Deaf and Hard of Hearing Services Office works
closely with the DVR Vendor Unit to maintain a list of qualified interpreters statewide for use by
rehabilitation staff serving individuals who are deaf.
B.
Communication Access to VR Offices
State and local VR offices serving a large number of individuals with hearing loss are advised to have a
Teletypewriter for the Deaf (TTY) and assistive listening device (ALD) such as an FM system for use by
DVR staff. The DVR Operational Policies and Procedures for DVR Counselors (Counselor Policy Manual)
or the Policy Manual for Vocational Rehabilitation Privatization Initiatives, as appropriate, explain the
procedure for purchasing such equipment. The DVR state office maintains a number of extra TTY and FM
Systems for in-house purposes (meeting or emergency use).
As videophones (VP) have emerged in the world of telecommunications in recent years, more and more
individuals with hearing loss have chosen to use a VP instead of a TTY. With videophones, those with
hearing loss are now able to talk in sign language directly with the counselors (visually) or through a relay
interpreter via the Video Relay Service (VRS). The VRS is acclaimed to be a “functionally equivalent
communication” tool. The counselors can also directly reach their consumers at home via the VP by
calling an 800 phone number to talk through video relay services (VRS). It is said that by speaking
through a VRS relay interpreter, communication is much smoother and quicker when compared to either
talking directly with a TTY or through a traditional relay service (TRS) operator with consumers that use
TTYs. Because DVR wants to improve access between consumers and counselors, the plan is to install
videophones in as many offices as possible.
All individuals with hearing loss are also encouraged to apply for and receive free-loan devices such as
TTY, home ring signaler, specialized phone, and amplifiers through the Florida Telecommunications Relay,
Inc. (FTRI) or one of local distribution centers authorized by FTRI to provide this equipment to qualified
residents for use at home.
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DVR STAFF
Historically, Division of Vocational Rehabilitation (DVR) has long recognized the unique challenges faced
by individuals who are deaf or have hearing loss. First, there is a pervasive communication barrier that
separates individuals from having access to needed services. Second, a lack of understanding of unique
problems experienced by the individuals who are deaf, late-deafened, hard of hearing, or deaf-blind may
negate successful rehabilitation outcomes. In recognizing these obstacles, the VR Administrator (Deaf and
Hard of Hearing Services) is assigned the responsibility of consulting with and providing training or
technical assistance to local DVR offices to ensure that an effective delivery of VR services is provided to
individuals who have hearing loss.
A. Professional Staff at DVR Headquarters
VR Administrator
The following covers the general functions of the VR Administrator who also functions as a State Coordinator
for Deaf and Hard of Hearing Services (SCD) within DVR.
1. Identifies needs, coordinates program planning and recommends policy for the development of quality
services.
2. Assists in the recruitment of qualified staff including Rehabilitation Counselors for the Deaf (RCD) and
Staff Interpreters, and assists Unit supervisors in the hiring process.
3. Develops and helps coordinate in-service training and orientation to deafness and hearing loss across all
staff levels in DVR.
4. Maintains VRI-Net (VR Intranet) resources and links on Hearing Loss, primarily on VR Services to
Consumers who are Deaf, Late-Deafened, Hard of Hearing, and Deaf-Blind (e.g., Brochures, Best
Practices, Manufacturer’s Single Unit Price (MSUP), Interpreter Manuals, and Video Vignettes in
American Sign Language).
5. Provides ongoing consultation to all programs of the agency that have a bearing on services provided to
individuals who are deaf, late-deafened, hard of hearing, or deaf-blind. This includes direct assistance to
supervisors and counselors in finding solutions to service delivery problems and expanding services.
6. Schedules training meetings for information exchange with DVR staff serving individuals who are deaf,
late-deafened, hard of hearing, or deaf-blind.
7. Reviews, evaluates and makes recommendations relating to grant projects and legislative proposals.
8. Provides consultation to DVR staff and serves as agency liaison on deafness and hearing loss.
9. Provides technical assistance to staff and community resources and helps develop programs for
individuals who are deaf, late-deafened, hard of hearing, or deaf-blind that supplement services by DVR.
Also, consults with facility representatives regarding grants for serving individuals who have hearing loss.
10. Maintains open lines of communication between deaf communities, hard of hearing organizations, and the
agency.
11. Provides annual reviews and evaluations of statewide DVR services to individuals who have hearing loss.
12. Functions as liaison with specialists on deafness and hearing loss in RSA Regional and Central Offices, in
other government agencies, in Regional Resource Centers, and in Research and Training Centers as well
as in other public and voluntary agencies.
22
VR Staff Interpreter/Program Consultant
The following is a listing of the general functions of the VR Staff Interpreter/Program Consultant who assists and
works with the VR Administrator in the coordination of program activities relating to Deaf and Hard of Hearing
services, including the following:
1. Provides sign language interpreting to internal and external Vocational Rehabilitation (VR) staff, customers
of the program, and partner agencies as needed.
2. Provides consultation and guidance to VR field staff and external customers on best practices in serving
consumers with hearing loss, hiring and working with interpreters, and guidance on any issues in working
with this population.
3. Maintains an updated intranet posting of hearing aid manufacturers’ costs and provide direct consultation to
the field and to vendors on the purchase of hearing aids.
4. Provides consultation to sign language interpreter vendors and assist the vendor unit on maintaining current
credentials and materials of sign language interpreter vendors.
B. Local DVR Staff Serving Individuals who are Deaf, Late-Deafened, Hard of Hearing, or Deaf-Blind:
Rehabilitation Counselor for Deaf (RCD)
The RCD is a significant member of the rehabilitation team with a full caseload or a majority of individuals who are
deaf, late-deafened, hard of hearing, or deaf-blind. Some VR counselors will have a combined caseload of
individuals who have hearing loss and other individuals with disabilities. Due to the unique service demands of
individuals with hearing loss, mixed caseloads are less than ideal.
Nevertheless, such mixed caseloads may be required in areas with sparse deaf and hard of hearing populations.
The RCD will carry out the same functions as any VR general caseload counselors. Optimal service for individuals
who are deaf, late-deafened, hard of hearing, or deaf-blind is provided by VR staff who not only have the ability to
converse in manual communication but also have the knowledge of deafness and hearing loss.
Important factors that should be taken into account in serving individuals who are deaf, late-deafened, hard of
hearing, or deaf-blind:
1. The communication factor. Interviews may take longer and allowances should be made for adequate time
to establish effective communication.
2. Limited knowledgeable resources. The counselor will need to spend more time in the
development/orientation of community resources.
3. Limited use of the telephone. Individuals who are deaf, late-deafened, hard of hearing, or deaf-blind
cannot easily be contacted for appointments, job leads, etc. VR counselors may need more time to make
contacts in person including travel time. A growing number of individuals who are deaf have access to
Teletypewriter for the Deaf (TTY) or video phones (VP); every VR area should install such TTY units to
improve communication linkage with members of the deaf community.
4. Isolation of the deaf and hard of hearing population. Individuals who are deaf, late-deafened, hard of
hearing, or deaf-blind may be unaware of available services. Thus, more time is necessary for outreach
efforts. "Caseload size and requirements" should reflect such activities. (VR support staff may need to
assist VR counselors with large caseloads.)
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5. Complexity of placement for individuals who are deaf or hard of hearing. The placement of individuals
who are deaf or hard of hearing is a difficult process requiring more than just the referral of the individual.
Often it involves on-the-spot assistance to individuals who are deaf or hard of hearing in job seeking, filling
out application forms, etc. Orientation to hearing loss for prospective employers is a frequent prerequisite
to successful placement.
In accordance to the Rehabilitation Act of 1973, individuals who are deaf are considered significantly disabled.
The RCD is encouraged to become involved in community activities sponsored by individuals who are deaf, latedeafened, hard of hearing, or deaf-blind in order to provide DVR outreach services and to become more aware of
unique problems experienced by these populations.
The RCD should inform the VR Administrator (VR Deaf and Hard of Hearing Services or SCD) of any gaps in local
services or resources. The RCD should also assist the administrator in developing needed services at the local
level. In addition, the RCD will serve as a consultant on deafness and hearing loss to local VR staff. Further, it is
of primary importance that the RCD work closely with their local programs to assure that individuals with hearing
loss receive coordinated and integrated services.
Staff Interpreter
The VR staff interpreter is a member of the rehabilitation team in providing critical services to VR staff and
individuals who have hearing loss. The staff interpreter facilitates communication in any related appointments or
activities.
Additional duties include coordination of interpreter services and teaming with the RCD or the VR general caseload
counselor to ensure that the individual who is deaf receives necessary accommodation.
SUPERVISION OF RCD AND VR UNIT STAFF
While the VR Administrator (SCD) oversees DVR Deaf and Hard of Hearing Services statewide as a member of
the DVR state office staff, he/she functions as a consultant to areas and local offices. The VR Administrator, on
occasion, communicates directly with local DVR staff serving individuals who are deaf, late-deafened, hard of
hearing, or deaf-blind including counselors, staff interpreters, and their supervisors. Direct supervision over RCDs,
their caseloads, VR Technicians, and Staff Interpreters is the primary responsibility of the local VR supervisors and
Area Directors.
The following factors need to be considered by Unit supervisors of VR staff serving individuals who are deaf, latedeafened, hard of hearing, or deaf-blind:
1. Interviews usually take longer with an individual who is hearing-impaired. Allowances must be made for
adequate time to effect a full understanding of the VR process.
2. DVR support staff should be encouraged to learn how to better serve individuals who are deaf, late
deafened, or hard of hearing. They should also be encouraged to learn sign-language to be able to
communicate with individuals who are deaf.
24
3. RCDs will require more time (travel, letter writing, etc.) to contact individuals who have hearing loss
regarding appointments, job leads, etc.
4. RCDs and other involved staff are encouraged to participate in community activities that may promote
better understanding of VR services by the deaf and hard of hearing. Such activities may include
attending local meetings or events.
5. RCDs are expected to spend extra time in outreach referral activities. This is important due to the often
isolated nature of the deaf and hard of hearing populations.
6. An RCD’s caseload size must be properly managed so that quality rehabilitation services can be provided.
7. Supervisors of RCDs and other involved staff are encouraged to participate in training activities relating to
deafness and hearing loss.
8. Supervisors should inform the VR Administrator (SCD) of any needs or concerns that should be
addressed either in area or statewide.
REVIEW OF DEAF AND HARD OF HEARING SERVICES
Upon request, the office of Deaf and Hard of Hearing Services will conduct assessments of services
provided by DVR to individuals who are deaf, late-deafened, hard of hearing, or deaf-blind in both areas
and statewide. These include on-site visits and surveys.
INTERAGENCY COOPERATION
DVR is the only public service agency with a legal basis to provide vocational rehabilitation services to
individuals with hearing loss as they seek to obtain, regain, or retain employment. DVR has an obligation to
strengthen its services to those who are deaf, late-deafened, hard of hearing, or deaf-blind through
cooperative efforts with other public and private resources.
The resources of other agencies must be explored and developed. The following is a partial listing of
resources that may be considered for meeting certain needs of individuals with hearing loss:
Deaf Service Centers
Adult Education/Special Ed. Programs
Rehabilitation Facilities
Sheltered Workshops
Florida Association of the Deaf (FAD)
Health Department
Mental Health Programs
District Employment/Security Offices
Centers for Independent Living
Hearing Loss Association of America (HLAA)
Association of Late-Deafened Adults (ALDA)
Hearing and Speech Centers
Post-secondary Educational Institutions
Religious Affiliated Organizations
United Way Affiliates
State Residential School
Florida Registry of Interpreters for the Deaf (FRID)
Public Schools
Legal Aid
Local Social and Economic Programs
Social Security Administration
Workers’ Compensation
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Appendix A
Guide on Hearing Loss and the Purchase of Hearing Aids
(Updated December 2011)
Table of Contents
Subject
Page
I. VR Case Management Practices on Hearing Aid Purchase
A. Hearing Aid Decision Tree
B. Service Fee Codes
C. Using Functional Limitations to Determine Appropriate
Hearing Aid Purchase/Chart
D. Best Practices for Counselors Serving Deaf &
Hard of Hearing Consumers
E. Other Best Practices
II. The Hearing Test
III. The Audiogram
A. Understanding the Audiogram
B. Audiograms
IV. Hearing Aids
A. Hearing Aid Styles
B. Chart: Types of Hearing Aid Technology
C. Chart: Comparing Hearing Aid Styles
V. Available Assistive Devices
Accommodations and Modifications
VI. Terminology
Definitions Relating to Deafness
25
26
28
31
33
34
35
36
39
40
42
44
45
Acknowledgement
Special thanks to Area 4 Tampa DVR Team for developing a number of outstanding materials that made it
possible for us to produce this section (Appendix A) of the Guide on Hearing Loss and Purchase of Hearing
Aids.
For Further Guidance
Any questions regarding hearing loss or hearing aid purchases can be directed to Deaf and Hard of
Hearing Services within the Bureau of Field Services at the Division of Vocational Rehabilitation (DVR)
State Office.
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HEARING AID DECISION TREE
REFERRAL STATUS:
Assistive listening devices are listed as a check box on the DVR Referral/Application.
APPLICANT STATUS:
Determine whether or not the consumer must have a hearing aid(s) in order to complete an evaluation.
This determination includes when a hearing aid(s) is not functioning or operating properly. If so, the
counselor should already have the documentation to either move the case to Plan Development status (10)
or to Extended Evaluation status (06) before the purchase of hearing aids. Efforts should be made to
acquire a loaner hearing aid, assistive listening devices (ALD) or an interpreter for the evaluation.
PLAN DEVELOPMENT AND ESTABLISHING VOCATIONAL GOAL:
The choice of a hearing aid should be based on the recommendation of a licensed audiologist that is
consistent with the hearing requirements of training and the job goal.
Use the charts in this guide to determine which aids to consider. In keeping with individual informed
choice, the suggested hearing aid should be acceptable to the consumer. If they prefer a more
complicated or higher tech hearing aid, they can be offered the opportunity to pay the difference in cost. In
all cases the choice of hearing aids must be determined by the requirements of the training and job goal.
When considering programmable or digital aids for persons with severe or profound hearing loss, the
counselor must recognize that these aids are most suitable for those who either had a progressive hearing
loss or became deaf at a later age. This is because they previously had residual hearing and understood
speech, unlike those who are born deaf or became deaf at a young age.
Thought must also be given to the possible use of other ALD, interpreters, note takers and other resources
to compliment the use of hearing aids. ALD are an excellent adjunct to hearing aids when the work duties
include meetings, orientations, telephone use and conversations in noisy surroundings. Hearing aids must
be equipped with a T-coil. The smaller aids (CIC, ITC) are not large enough to accommodate the T-coil.
Important Notes:
Regardless of status, comparable services and benefits should always be considered first.
Regarding students 16 years of age or older who are seeking School-to-Work Transition Services, DVR
does not generally purchase hearing aids for those still attending high school unless the eligible student is
in the final term of school and requires such aid(s) for post-high school training and/or employment.
However, DVR may sponsor the cost of vocationally relevant hearing aids for a DVR eligible transition
student who needs the aid(s) to benefit from paid and non-paid community work experiences. DVR
purchase of the aid(s) should only occur when no other comparable benefit is available from the school or
other resources, including Children’s Medical Services (CMS) and Medicaid. (Revised 11/27/06).
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SERVICE FEE CODES
EAR NOSE THROAT OFFICE VISIT
992410 Office Consult TJ 15 Min: Basic Visit (To check any problems that the person
may be having with his/her ears). Also use other codes for more intensive visits:
992420: Office Consult TJ 30 Min. or 992430: Office Consult TJ 40 Min.
Get medical clearance for Hearing Aid fittings
Check with the doctor for ENT special codes.
BASIC AUDIOLOGY: TESTS, EXAMS and EVALUATIONS
925530 Pure Tone Audiometry Threshold (air & bone)
925560 Speech Audiometry Threshold with Speech Recognition
OR
925570 Comprehensive Audiometry Threshold Evaluation and Speech Recognition (both
925530 & 925560)
925670 Tympanometry (impedance testing)
925680 Acoustic Reflex Testing; Threshold
925900 Hearing Aid Examination and Selection: Monaural (One)
925910 Hearing Aid Examination and Selection : Binaural (Two)
925911 Special Hearing Aid Examination and Selection: Binaural 7-1/2 Hour
925060 Evaluation of speech, language, voice, communication and/or auditory processing
HEARING AIDS, EARMOLDS and BATTERIES
C99801 Hearing Aid Repair
C99810 Analog Hearing Aid
C99820 Programmable Hearing Aid
C99830 Digital Hearing Aid
999010 Professional Fee for Monaural (One) Hearing Aid* ($500)
999020 Professional Fee for Binaural (Two) Hearing Aids* ($950)
990700 Supplies & Materials (this code includes ear molds**, batteries & Cochlear Implant Cords)
* This fee covers programming, fitting, dispensing, up to 2 follow-up visits after the initial 30-day
trial period, earmold, and a 1-year warranty)
**When purchasing earmold(s) from a physician, use Code 990700 (“Supplies and Materials”).
When purchasing earmold(s) from an audiologist or hearing aid dealer, you may face problems
using code 990700 to pay for it as this may be restricted to physician vendors only so you may
need to use Code B10004 (“Medical Supplies”). Important Note: do not use this code:
CV5275 (ear impression) for earmold(s) - only use either code: 990700 or B10004. However,
both codes (990700 or B10004) should NOT be used when purchasing new hearing aid(s);
instead, use professional fee codes which includes the cost of earmold(s).
As for hearing aid components (i.e. telecoil) that may come with an additional cost, we do
not have separate codes. On the purchase/authorization form, list such costs along with
the cost of hearing aid and total the cost. Add a statement on the form explaining what the
additional costs were for. Also mention this in the case notes.
28
TECHNICAL AIDS and DEVICES
G10250 Other Hearing Devices (tactile alarm clocks, assistive listening devices, regular
FM system, electronic/amplified stethoscope that works with hearing aids, etc.)
C99801 Repair of Other Hearing Devices (e.g. FM System)
HEARING AID FM SYSTEM (AUDIO SHOE)
999080 Professional Fee for installation of FM System Hearing Aid (Audio Shoe), included with the
fitting of new hearing aid(s). (Either monaural or binaural hearing aid(s). Include
adjustments, counseling, and 3-4 follow-up visits). The fee is $200.
999090 Professional Fee for installation of FM System Hearing Aid (Audio Shoe), not included with
the fitting of new hearing aid(s). (Either monaural or binaural hearing aid(s). Include
adjustments, counseling, and 3-4 follow-up visits.) The fee is $300.
C99890 Hearing Aid FM System (Audio Shoe) – see Hearing Aid MSUP for Actual Cost.
G10250 Other Hearing Devices (ex: for FM system itself- Micro link, Smart Link, MLx Transmitter)
Note: Also add Hearing Aid Professional Fee (i.e. $500 Monaural) if a new hearing aid is
being purchased/fitted with the FM System Hearing Aid. Reason: each requires
separate fittings and adjustments to ensure that both work well together.
HEARING AID CHECK and FITTINGS
925920 Hearing Aid Check: Monaural
925930 Hearing Aid Check: Binaural
925940 Electroacoustic Evaluation Hearing Aid: Monaural
925950 Electroacoustic Evaluation Hearing Aid: Binaural
925994 Hearing Aid Evaluation, ear mold, and counseling
IPE SERVICES (DROP-DOWN LIST)
(Also RIMS Service Types)
Physical Restoration – Basic Visit (992410) and all audiology testing: 925060, 925530, 925560,
925570, and 925680, and supplies/materials [990700 (physician vendor) or B1004 (nonphysician vendor)].
Hearing Aids – Hearing exam codes, hearing aids, technical aids, and hearing aid checks.
Technical Aids/Devices - Other hearing devices (G10250)
29
USING FUNCTIONAL LIMITATIONS
TO DETERMINE APPROPRIATE HEARING AID PURCHASE
While functional limitations of a particular hearing loss may be identified as early as in the Preliminary
Assessment, the decision to purchase hearing aids is more appropriately addressed at IPE planning. The
exception is when the hearing aid is essential for participation in assessments (i.e. vocational or
psychological assessment). Every effort should be made first to get a loaner hearing aid or FM listening
system. A sign language interpreter can also be used if the consumer uses sign language.
A particular aid being purchased should be based on the individual’s ability to hear and understand speech. A
particular occupation and daily function may also affect the choice as to the type of a hearing aid. For instance,
some individuals who are congenitally and profoundly deaf can hear and understand speech so they may require
sophisticated hearing aids with added features. However, many, in general, do not hear and understand speech.
The distinction can and must be made on what is necessary for effective communication while receiving IPE
services leading to an employment outcome. In addition, the individual’s abilities define what his/her vocational
impediments are and whether or not the purchase of hearing aid(s) is vital to achieving an employment outcome.
Depending on the individual’s abilities, there are two broad categories used for identifying the type of
hearing aids, which should be obtained.
1.
Daily Interaction involving sound reception and recognition only. This category generally
applies to those who are Deaf.
Individuals who are Deaf handle daily living and work functions by utilizing technology that provides
visual and sound awareness to alarms, moving vehicles, warnings, machinery etc. These activities
generally can be accommodated by a basic hearing aid (e.g., analog, basic digital) and provide
amplification in order to secure the safety and/or attention of the individual on the job. Examples are
working in warehouses where forklifts are used, in landscaping, carpentry work, etc. The basic
requirements of these types of jobs are to be able to hear sounds (e.g., machinery noise, alarms).
The provision of top of the line digital, and/or programmable aids would not apply to these individuals
who utilize hearing aids for sound awareness only.
In fact, many occupations may lend themselves to utilizing a Rehabilitation Engineer for the provisions
of flashing lights and other assistive technologies.
2.
Daily interaction requiring speech recognition and understanding. This category generally
applies to those who are late-deafened or hard of hearing since they require a more finely tuned
decision process. The following points bring to light some examples of important aspects in
communication that will require us to purchase higher functioning hearing aid(s):
A. Daily interaction (e.g., training, work) requiring face-to-face communication that involves visual feed
back and speech reception.
B. Daily interaction requiring ongoing use of the phone. A phone amplifier may be essential in
addition to a hearing aid.
C. Daily interaction involving recognition of high-pitched voices (e.g., children’s voices) that is part of a
required daily job function (e.g., teacher).
30
D. Daily interaction requires extensive communication with the hearing public or hearing co-workers.
E. Daily interaction requires the ability of the individual to hear the fine-tuning of machinery or
appliances in order to determine if they are working correctly.
F. Daily interaction involves loud background noises that interfere with their ability to hear and
understand speech.
Purchasing Hearing Aids and Providing Accommodations
When purchasing a hearing aid, a distinction is made to determine which type of hearing aid is the most
appropriate: behind-the-ear (BTE), on-the-ear (OTE), in-the-ear (ITE), in-the-canal (ITC), or completely-inthe-canal (CIC). In general, BTE is the preferred type to purchase for ease of care and operation as well as
longevity of batteries. The individual’s physiological aspects (i.e. hearing and speech capabilities), daily
living, and job functions (i.e. work environment) determine the best kind of aid to be purchased (e.g.,
regular, waterproof). Other concerns may need to be addressed. For example, is the work site hot and
humid? Is the work site noisy? Is there equipment (e.g., headphone, gas mask, special vision protection
device) that may interfere with the use of a particular style of aid?
If an individual who is profoundly deaf with fair to good speech (may be able to speak face-to-face with an
individual without assistance) chooses a job that requires extensive communications (e.g., schoolteacher,
counselor), purchase of assistive listening devices and/or interpreter services should be considered.
For those who are late-deafened or hard of hearing, there may be jobs where the ability to hear and
understand speech is crucial (e.g., telephone operator, telephone customer service representative, bank
teller, receptionist, retail sales, attorney, florist) and may require a higher-level digital hearing aid that will
enable these individuals to perform various functions/roles in different environments more effectively.
Other jobs (e.g., computer operator, x-ray technician, housekeeper, carpenter, driver, building trades,
printer operator, mechanic, stockroom, forklift operator) have different performance and safety
requirements that may not require extensive use of communication. Thus, it is very helpful to do a
thorough job analysis in determining what else the individual may need to perform on the job effectively.
Making the Decision
When the individual and counselor arrive at an appropriate choice of employment outcome, the first
decision is whether or not the purchased hearing aid will enable the individual to complete not only the
services listed on the Individual Plan for Employment (IPE) but also satisfy the job requirements. In
addition, involve the individual in the discussion as to how the recommended hearing aid would be more
effective, practical and beneficial for daily interaction and employment. If not, assistive listening devices
(e.g., visual alert, amplified phone, FM system, TTY) should be considered as a supplement to the hearing
aid. Other approaches may include the use of a professional sign-language or oral interpreter, CART
(computer assisted real-time captioning) service, or even simpler, no-cost alternatives like sitting near the
speaker in meetings, providing copies of prepared texts, or using media. If noise interferes with the job
performance, other means may be considered such as relocating or covering noisy equipment (e.g.,
printers, copiers), or moving the individual to a quieter location. For other example accommodations,
please see pages 44-45.
31
An unusual shaped audiogram and need for extra special features may necessitate a certain kind of
hearing aid and should be discussed thoroughly with the audiologist and/or the hearing aid provider.
Counselors should also work with the audiologist and/or hearing aid dealer in taking the vocational goal into
serious consideration and not recommend a hearing aid based on degree or type of hearing loss alone.
How Many Hearing Aids to Buy?
We may consider the purchase of two hearing aids for the individual if highly recommended and welljustified by the audiologist, especially for those who rely on these aids for daily communications. However,
if the individual is receiving two aids for the first time as opposed to having just one in the past, the
counselor and the audiologist should discuss the justification and purpose of having two aids before the
purchase is made.
32
BEST PRACTICES FOR COUNSELORS SERVING
CONSUMERS WITH HEARING LOSS
February 2010
 An Ophthalmology exam must be obtained in all cases of deafness, retinitis pigmentosa, and
usher syndrome, and may be considered for others.
 For audiological evaluation, we only accept audiogram and recommendation with signature from a
state licensed or nationally certified audiologist with either a designation of “Certificate of
Clinical Competence in Audiology (CCC-A)” or “Board Certification in Audiology.” We also
accept evaluation done by a staff under the supervision of a qualified audiologist and the report
must include audiologist’s signature and designation. We cannot accept audiograms from licensed
hearing aid specialists.
 Audiological evaluations must be recent (no more than 6 months old) for those to be fitted with
hearing aids. Because of the Order of Selection, it may be recommended that we use older reports
(1-2 years) rather than sending consumers for new audiological testing.
 Individuals who are suspected of having ear diseases should be referred to ENT (ear, nose throat)
specialists for an evaluation and Medical clearance for hearing aid fitting. Either the consumer will
notify the counselor of a possible medical condition in the ear or the audiologist will recommend a
referral after a hearing evaluation.
 Audiologists and counselors/consultants should justify their recommendation of high-level digital
hearing aids over mid-level or lower-level digital aids, programmable or analog hearing aids.
Remember, it is important for the counselor to work closely with the audiologist or hearing
aid specialist and consider fully the type of training the consumer is involved in or the job
the consumer will do and not just focus on the degree and type of hearing loss.
 Purchase hearing aids from reputable audiologists or licensed hearing aid specialists.
 On the Individual Plan for Employment (IPE), it is a good idea to include the individual’s need to
start saving for future hearing aids (drop down “Counseling and guidance”). Some possible
wording under the individual responsibility section could be "consumer agrees to budget money
each month to purchase own hearing aids and also to pay for future maintenance costs such as
batteries, earmolds, extended warranties and repairs.”
 Trial periods for hearing aids: By state law, individuals have 30 days to try out the hearing aids. If
not satisfied for whatever reason, tell them to return it before the 30 th day.
 Telecoil - very important!!!! Many users benefit from this T-switch, which is important for telephone
usage, and also for using assistive listening devices [ALD’s] (including FM and special sound
systems) in auditoriums, meeting rooms, etc. Most canal or completely-in-the-canal hearing aids
do not have this.
33
 The smaller the hearing aid, the more expensive. Stick with the behind the ear hearing aids or
in-the-ear canal type. In-the-canal and completely-in-the-canal hearing aids prices tend to be more
expensive than BTE’s, OTE’s and ITE’s, and should only be purchased for extenuating reasons. In
addition, they do not last as long as behind-the-ear and in-the-ear hearing aids. A high rate of
repairs occurs due to wax build-up, ear drainage, and oil production.
 Maintenance/repairs of hearing aids: audiologist or hearing aid specialist can be asked to
examine the hearing aids. If further repair is needed, then it will be sent to the factory. There is
usually a standard cost for repairs ($175- $300), regardless of how minor or major the repair work
is.
 Warranty: most new hearing aids come with a one-year warranty, although more are coming out
with two-year warranties. It can be extended at extra cost.
 If two hearing aids are recommended and the consumer relies on the hearing aid for speech
discrimination and sound localization, then buy 2 (don’t base purchase decision on cost alone).
 If in doubt about consumer cooperation, then purchase one hearing aid. If the consumer follows
through with the IPE (gets a job), then purchase the second hearing aid.
 Cochlear implants- require state prior approval and based on strict criteria.
 Returning Individuals: If an individual returns to Vocational Rehabilitation (VR) with any hearing
aid request, the individual must meet all of the VR eligibility criteria. (See “Eligibility
Determinations”, page 30)
 What if the returning individual already got a hearing aid from VR? If the individual returns to
VR with a request for a new hearing aid after one was already purchased for him/her less than 5
years ago, the VR counselor will need to evaluate his/her situation carefully. There is no VR policy
or guideline on time limits as to when the individual can come back to VR for hearing aid
replacement or repair. Some individuals may believe that his/her hearing aid is broken, lost, or
damaged beyond his/her control. The hearing aid should first be sent to an audiologist or hearing
aid specialist to see if it can be repaired. If not, VR may consider purchasing a new one if the
hearing aid is critical to the training or the job of the eligible consumer. Many hearing aids
generally last more than 5 years. Again, we need to emphasize responsibility and care of the aids
to our individuals, and encourage them to save money for future replacements. This is especially
true with the implementation of the Financial Participation Determination and Order of Selection.
 For counselors who are not familiar with working with consumers with hearing loss, they should
consult with a Rehabilitation Counselor for the Deaf, a Supervisor or a Consultant in their area for
any questions they may have.
34
OTHER BEST PRACTICES
1. Self-Referrals versus Direct Referrals from Audiologists or Hearing Aid Specialists – while we
encourage those with hearing losses to come to VR to apply for our services, we also accept referrals
from audiologists or hearing aid specialists. Such referral will not guarantee the individual’s eligibility.
2. Eligibility Determinations Hearing loss alone does not determine the individual’s eligibility for VR services
but serves as a starting point (loss of 30 dB or greater as an example).
There must be strong evidence of impediments (e.g. communications, noise, use of phone as an
essential function of the job, job jeopardy) that may affect:
 the individual’s ability to participate in training and or job, and
 the individual’s demonstrated desire to work or keep a job.
Regarding whether or not “the individual requires VR services to prepare for, obtain, and retain
employment,” the main question remains “does the person require VR services?” The individual
and the counselor must determine that:
 the VR services are essential to his/her success (examples: personal adjustment counseling,
employer intervention or education, exploration of assistive technology), and
 the VR services will impact the individual’s success in employment.
If an individual is employed, it is recommended that the individual obtain a letter from the employer
indicating that he/she cannot perform his/her job functions without hearing aid(s). However, a letter
is not mandatory.
3. Audiograms can only be accepted from nationally licensed/certified audiologists.
4. Any individual suspected of having diseases of the ear(s) should be referred to an otologist or
otolaryngologist (ENT). This referral will occur either with the consumer notifying the counselor of a
possible medical condition in the ear or the audiologist recommending such after a hearing evaluation.
5. Any individual who is deaf must go for Ophthalmological Evaluation to examine possible diseases of
the eye. Referrals for those who are hard of hearing are optional.
6. When purchasing hearing aids:
a. Vocational Rehabilitation (VR) Counselor should follow the recommendation by the audiologist for
a hearing aid that best fits the needs of the individual. If the VR Counselor has questions about the
recommendation, he/she should contact the audiologist.
b. The hearing aid can be purchased from either the audiologist who performed the hearing
evaluation and provided a recommendation, or a hearing aid specialist. The VR Counselor can
confer with a neutral VR Audiological Consultant about the recommendations.
c. Then, the VR Counselor will discuss with the individual as to the type of recommended hearing aid
and both will agree to the purchase. If requested and determined appropriate (reference [6] b.,
above), the VR Counselor shall honor the individual’s preference to be served by the same
audiologist or the hearing aid specialist who made the initial referral to VR.
d. Consumer Informed Choice – in addition to individual’s choice of an approved audiologist or a
hearing aid specialist (as a vendor) for services, the individual will be provided a hearing aid that
will enable the individual to perform successfully on the job or while in training. If the individual
wishes to seek extra features (e.g. “bells and whistles”), he/she will pay the difference.
e. The VR Counselor will notify the audiologist or the hearing aid specialist and authorize services
using appropriate RIMS codes to process the authorization.
f. After fitting of the hearing aid and satisfaction of the individual with the hearing aid purchase, the
VR Counselor shall receive both a signed authorization and an itemized invoice from the
35
audiologist or the hearing aid specialist listing the price of a hearing aid from “Manufacturer’s
Single Unit Price (MSUP)” plus a DVR-established professional fee. The VR Counselor must verify
the hearing aid price match with MSUP posted on DVR Intranet (See DVR Policy 12.06).
7. Individuals need to be reminded of their responsibility for repairs, maintenance, and future replacement
of their hearing aids.
a. Counselors are encouraged to develop and maintain good communications and relationships with
audiologists and hearing aid specialists as well as other vendors.
[Special thanks to Buyer’s Haven (www.buyershaven.com) for giving us permission to copy the following
article similarly titled as “The Hearing Test” as addressed to the consumer. (February 24, 2003)]
THE HEARING TEST
A complete hearing test done by a person who knows what they are doing consists of four standard
components. They are the Pure Tone Air Conduction test, the Bone Conduction test, the Speech
Reception Threshold test, and the Speech Discrimination test. It is very important that you receive each of
these tests to ensure that your results are accurate and that you are fitted for the proper hearing aid if
appropriate.
Below are further explanations of these tests:
Pure Tone Air Test: Many of you are familiar with "Pure Tone Air Testing". This is when a tester places
headphones (some testers now use earplugs for higher quality) over your ears and plays different tones.
You are told to indicate when you can hear each tone in one of many ways that vary with each testing
machine. This test determines how well you hear at different frequencies. The normal human ear can hear
tones from 20 to 20,000 cycles per second.
Bone Conduction Test: During the Bone Conduction test an instrument is placed against the mastoid bone,
which is just behind your ear. The tester then plays the same tones as you heard during the Pure Tone Air
testing. You usually indicate when you hear the tones in the same fashion as the "Pure Tone Test". The
Bone Conduction test will help determine whether your hearing loss is due to outer ear or middle ear
problems. This can also be caused by inner ear nerve damage. In some cases, the person giving you the
test may stop here and refer you to a physician. In some states, this is mandatory under certain conditions.
Other times, a tester may stop here because you do not appear to have a loss. This is because the next
two tests are mainly for fine-tuning a hearing aid to your needs.
Speech Reception Threshold Test: The Speech Reception Threshold is the softest point at which you are
able to repeat words correctly fifty percent of the time. The Speech Reception Threshold test indicates the
level of sound you need before you can hear and understand words. This test is very important in the
programming of your hearing aid(s).
Speech Discrimination Test: In the conventional Speech Discrimination test, the hearing specialist presents
25 to 50 standardized words to you, which you are asked to repeat. Word discrimination testing serves
three purposes:
1. Test words given at normal speech levels indicate how the individual is functioning without hearing
aids.
36
2. Your best speech discrimination is found by testing at different intensity levels to locate the level
that produces the best score.
3. Speech testing gives you an opportunity to hear what amplification can do for you. (What it may
sound like with a hearing aid.)
USEFUL INFORMATION AVAILABLE ON THE INTERNET
There are internet websites that provide useful information on how to better understand the audiogram as
well as hearing loss. The following is an example worth reviewing: http://www.earinfo.com/howread1.html
UNDERSTANDING THE AUDIOGRAM
The Audiogram is a printed report of an individual’s hearing tests. On the graph itself there are two sets of
numbers and two sets of symbols (X and O).
The numbers across the top of the Audiogram are measured in Hertz (Hz) from 125Hz to 8000Hz. These
numbers measure the pitches an individual can hear. The low numbers, (125Hz to 500Hz) measure the
ability to hear very low pitches, the high numbers (4000Hz to 8000Hz) represent the ability to hear very
high pitches. The mid-range numbers (500Hz to 4000Hz) are considered to be speech range.
The numbers down the side of the Audiogram are Decibels (dB) and represent loudness. They are from
minus ten (-10dB) to 120 dB. The lower numbers represent very quiet sounds while the larger numbers
represent very loud sounds.
The audiologist measures how loud a certain pitch must be made for an individual to hear it and marks that
point on the graph with an X for the left ear and an O for the right ear. The audiologist then continues to
mark the graph at all frequency (Hz) levels. In a normally hearing individual the (X)’s and (O)’s would fall
within the pitch range of 250 Hz to 2000Hz at 30 dB or lower.
Pitch (frequency - Hz) - from 125 Hz to 8000 Hz
Loudness (intensity - measured by decibels dB) - from –10dB to 120 dB
Symbols
X is for left ear O is for right ear
1. Air conduction testing: This test determines the amount of hearing loss for particular pure tone
frequencies (Hz)
2. Bone conduction testing: the point at which sound is heard when the conductive mechanism of the
ear (nerves, ear drum, etc.) is bypassed. A bone vibrator or oscillator is placed on the mastoid bone
sending vibrations. This test helps to determine if there is a hearing loss in the outer or middle ear.
Unmasked, Masked: “Masked” is a process where noise is introduced during the air or bone conduction
testing. Noise introduced in the non-test ear so that if the test tone should cross to the tested ear, it will not
be perceived.
Symbols: Unmasked: O right ear
X left ear
Masked:
< right ear
> left ear
3. Speech Tests
PTA Pure Tone Average: 500, 1000 and 2000Hz average dB at which a tone is heard.
37
SRT- Speech Reception Threshold- lowest dB level at which a person can correctly identify 50% of test
words spoken by the audiologist.
Speech Discrimination - is the number of words correctly repeated from a test list presentation
38
These are sample “sounds.” If a person has a moderate hearing loss, he/she will have difficulty hearing a
baby cry or an air conditioner. If a person has a severe hearing loss, he/she will have difficulty hearing a
dog barking or a piano playing.
39
40
HEARING AID STYLES
Listed and shown below are the most common hearing aid styles (types). The smaller the hearing aid, the
more expensive it is. Efforts should be made to purchase the best-priced hearing aid(s) possible and most
appropriate style.
Behind the ear (BTE)
It is a small plastic case that sits behind the ear and connected to an earmold by a piece of clear tubing.
On the Ear (OTE) Also known as Open Fit
This is a new style of the BTE that is smaller and uses domes or tubes instead of regular earmolds.
In the Ear (ITE)
Fits in the contoured portion of the outer ear and is custom-made. It is approximately the size of a quarter.
In the Canal (ITC)
This is a small instrument and is less visible than the above hearing aids. More cosmetically appealing, but
it is priced higher than the ITE and BTE.
Completely in the Canal (CIC)
Fits very deep into the ear canal. It is the most cosmetically appealing style of hearing aid because it is
almost undetectable. Significantly more expensive than the above styles and should be purchased only in
extenuating situations. Cosmetic reasons are not a sufficient justification.
Cros/Bicros (Extra Feature)
Designed for someone who has no hearing in one ear and either normal hearing or a hearing loss in the
other ear. Helps re-route sounds that are coming into the bad ear and send them into the better ear. This
helps the individual hear sounds from both sides without having to turn your head. This is available mostly
on behind the ear style hearing aids.
Left to Right: behind the ear, in the ear, in the canal, completely in the canal
41
TYPES OF HEARING AID TECHNOLOGY (CIRCUITRIES)
Type of Hearing Aid
ANALOG**
Also known as
traditional hearing
aid or linear
circuitry
For all hearing losses
Description
Regular quality hearing aids that
have one or two controls for the
audiologist to make adjustments and
a volume wheel. Have fewer
options than the other aids and
cannot be manipulated or adjusted
by a computer. Any major
adjustments require the hearing aid
to be returned to the lab. Runs on
electrical current.
**Analog aids will eventually phase
out and no longer be sold on the
market. See note below.
PROGRAMMABLE
Aids are programmed
through digital
technology, but the
sound is ultimately
converted and
amplified using analog
technology (electrical
current)
For most hearing
losses
Costs
Consumer Profile
See
- Equal tolerance to loudness through the
Manufacrange of frequencies
turer
Single
- Large or near normal dynamic range (no
Unit Price tolerance problems with loud sound)
(MSUP)
- Mild to profound hearing loss with poor
word recognition ability (less than 60%)
- Person has limited mental ability or
dexterity to manipulate a digital or
programmable aid
- Previous long time user of linear circuitry
Come with many adjustable
controls, which may be computeraided. Their advanced circuitry
makes enough automatic
adjustments to incoming sounds that
a volume wheel is not necessary.
Some come with a personal remote
for volume. Due to their
programming capabilities, they are
adaptable to a wide range of hearing
losses and can be reprogrammed to
compensate for any changes in
hearing. Also allows for multiple
memory programming, enabling the
user to change the hearing aid
settings.
- Lifestyle with an individual having limited
interaction, is homebound, or has few
listening or communication demands
- Variety of listening demands at training or
work, such as meetings, phone usage,
loud background noise
See
Manufacturer
Single
Unit Price - Good for those with progressive hearing
(MSUP)
loss
- Abnormal shape of audiogram, which are
difficult losses to accommodate with
traditional hearing aids
- Small dynamic range or very different
tolerances to loudness in low frequencies
as compared with the high frequencies
- Word recognition of 60% or better in at
least one ear, regardless of degree of
hearing loss
- Person has finger dexterity & mental
abilities to utilize remote control
42
Type of Hearing Aid
DIGITAL
Newest technology And the most
expensive
For mild to moderately
severe hearing losses
Description
The way they amplify sound is what
makes the difference. Use digital
signal processing (DSP) instead of
electrical current. Contain a
computer chip and programmed
through a computer software
program. Easily reprogrammed for
changes and less need for sending
to the lab. Able to separate
unwanted noise from the desired
speech information and eliminates
much of the distortion common in
analog hearing aids. Allows the aid
to automatically adapt to changes in
the auditory environment without
any user manipulation. Computer
memory retains the preferred
listening program for various
environments. Range from low-level
(very basic) to high level (full of
extra and more expensive features)
Costs
Consumer Profile
See
- For those with mild to moderately severe
Manufachearing losses
turer
Single
- For those with an active lifestyle, a variety
Unit Price of listening demands and the desire for
(MSUP)
the most advanced technology
- Takes a lot of patience and adjustments to
get used to the aids. Requires several
trips to the audiologist for adjustments.
Must be committed and motivated
- Good for persons with progressive hearing
loss as aid can be modified in the office. It
is like having two hearing aids
Important Note: Analog hearing aids will eventually phase out and no longer be sold on the market.
Hearing Aid manufacturers are now incorporating digital technology into all types of hearing aids offering
different levels of functional capabilities such as basic (limited), regular, or high-end. It can be said that
basic digital hearing aids replace “analog” hearing aids but they differ in how they process sounds.
43
COMPARING HEARING AID STYLES
Features
Behind the Ear (BTE)
Hearing Loss Fitting Range Mild to Profound hearing loss
Telecoil (T-Coil) Available
Instrument Life
Yes
5 – 8 years
Battery Life
Cros/Bicros Availability
Advantages
2-3 weeks
Yes
- Most powerful
On the Ear (OTE) also “open In the Ear (ITE)
fit”
Mild to Moderate hi-freq loss
Mild to Severe hearing
loss
Yes, on some
Yes, on most
4-5 years
4 - 6 years
1-2 weeks
- Less visible (very sleek
looking)
- Least expensive
- The dome doesn’t plug the
ear like the BTE earmolds
and the small ITC aid
- For all hearing losses
- Earmolds can be changed if
problems with feedback,
drainage, etc.
- Can be modified with
connections to sound
sources such as
assisted listening
systems (FM and
Infrared) and TV
Disadvantages
- Batteries last longer
- Earmold may need to be
remade periodically,
especially if damaged or illfitted
- Larger and more noticeable
than other aids
- Uses small batteries
- Lacks manual adjustments
due to the small size
- Best for high frequency
losses as the ear canal is
much more open with the
dome
1-2 weeks
Space permitting
- Holds larger sound
amplifier than in the
canal aid
- Can have more
features such as
directional
microphone,
compression,
telecoil and multiple
memory programs
- Chronic feedback
due to
closeness of
microphone
and receiver
- Small size batter door
&
volume control can
be
difficult for some to
adjust
- Can be damaged by
earwax
and drainage
44
COMPARING HEARING AID STYLES (Continued)
Features
Hearing Loss Fitting Range
T-Coil available
Instrument Life
Battery Life
Cros/Bicros Availability
Advantages
Disadvantages
In The Canal (ITC)
Mild to Moderate Hearing Loss
On some hearing aids
3 - 5 years
7 – 10 days
No
- Cosmetically appealing
Completely in the Canal (CIC)
Mild to Moderate Hearing Loss
Rare
3 - 4 years
5 - 7 days
No
- Smallest size – invisible
- Good sound reception due to
placement of the microphone in
the ear canal
- Small battery, shorter life
- Receiver close to eardrum –
provides natural loudness
- Feedback (whistling) due to
closeness of mike and receiver
- Most expensive
- Must have large ear canal
- Not for severe to profound hearing loss
- Very small volume button
- Problems with wax buildup, oil
production and ear drainage
problems
- Very small battery, short life & hard to
place in
hearing aid
- No volume control
- Feedback problems
- Highest repair rates due to ear wax buildup
&
drainage, and oil production
**Average life-span of a hearing aid depends on how well the consumer takes care of the aid and their
lifestyle. For example, an office worker’s aids will last longer than someone who works outside all the time.
**Digital hearing aids cause faster battery drainage than analog and programmable hearing aids.
45
SAMPLE ACCOMODATIONS AND MODIFICATIONS**
Deaf, late-deafened, hard of hearing and deaf-blind individuals have varying hearing losses, have different
communication modes and different limitations. As a result, accommodations will vary and should be
determined on a case by case basis. The following should be considered when trying to determine the
appropriate accommodations: what limitations are the consumer with hearing loss experiencing? How do
the limitations affect their job performance? What job tasks are problematic as a result of the limitations?
Will the available accommodations reduce or eliminate the problems? Has the consumer been consulted
regarding possible accommodations? Below are some sample accommodations listed by the Job
Accommodations Network for the workplace.

For face-to-face communication situations
o Write notes (many deaf and hard of hearing persons who use American Sign Language
may have difficulty with reading and writing so this may be difficult for some)
o Using a computer to type messages back and forth
o Using Ubi Duo (consists of two flat, matching keyboards with tilting screens. What one
person types shows on the other person's screen and vice-versa)
o Use of email or text messages instead of face-to-face meetings
o Hire a qualified sign language interpreter, especially for the longer meetings
o Use assistive listening device like FM system or portable amplifier (such as Pocket Talker)

For group or meetings
o Hire a qualified sign language interpreter or use video remote interpreter (VRI)
o Use an assistive listening device
o Try to meet in small groups in a quiet environment - round tables come in handy
o Talk with staff about meeting etiquette (one person should talk at a time, don’t cover
mouth, etc)
o Give agenda and written materials before the meeting or offer minutes afterwards
o Have another worker provide note taking on laptop during the meeting
o Contract out for CART reporting (Communication Access Real-Time Translation)

Telephone Communicating
o Use of telephones with amplification and/or clarity technology
o Hearing aid compatible headset or amplified noise canceling headset (need t-coil option in
hearing aids)
o Captioned telephone (Cap-Tel phone)
o Teletypewriter for the Deaf (TTY)
o Voice Carry Over VCO for consumers who can speak but not hear on the phone
o Video relay service by using one of the following methods: TTY, personal computer or
videophone equipment (this is a big favorite of many deaf, hard of hearing, late deafened
and deaf-blind individuals who use sign language)

Communicating in the field
o Use e-mail or instant messaging (IM) instead of voice phone or use mobile two-way radio
or cell phone with text messaging capability
o Use a personal paging system
46


o Install lighted fire strobes and other visual or vibrating alerting devices to supplement
audible alarms
o Use a portable videophone or TTY where relay service is available.
o
Notification Systems
o Telephone ring, doorbell, fire/smoke alarm, carbon monoxide, doorbell, baby cry, weather,
sound signaling devices to use at work and at home
o Signals by light, vibration, strobe or paging systems (some are optional, others are
standard)
o Can buy individually or by the system. Some system names: Sonic Alert, Clarity, Ultratec
Simplicity, Bellman & Symfon, Silent Call Communications
Alarm clocks
o Outlets to connect to a lamp or use with bed vibrator
o Buzzers up to 98 dB
o Travel clocks
o Use cell phones that vibrate to wake up a person
**From Job Accommodations Network: http://www.jan.wvu.edu/media/hearing.html
DEFINITIONS RELATING TO DEAFNESS
Adventitious Hearing Loss - person is born with normal hearing but through illness or accident, losses
their hearing.
Audiogram - a graph of hearing acuity recorded during hearing tests. Shows the degree and type of
hearing loss.
Bilateral Hearing Loss - loss in both ears.
Congenital Hearing Loss - person is born with deafness or hearing loss.
Deaf - typically used to describe persons with a severe to profound hearing loss, many of whom will still
have residual hearing, but it is not useable for speech discrimination purposes; hearing loss of such
severity that the individual must depend primarily upon visual communication such as lip-reading, writing,
manual communication and gestures. This is usually a 70db loss or greater in both ears and a speech
discrimination score of 40% or less in the better ear.
Hard of Hearing - a hearing loss resulting in a functional loss, but not to the extent that the individual must
depend primarily upon visual communication. This is usually a 30db loss in the better ear with speech
discrimination below 50%; a person with a mild hearing loss who normally communicates by lip-reading
may find benefit from use of a hearing aid.
Hearing Aid - device used to amplify sound.
47
Hearing Impairment - hearing loss that is sufficient enough to interfere with communication and daily
living.
Lip reading - “Speech Reading”- watching a person’s lips and facial movements to understand what is
orally spoken. Typically less than 40% accuracy rate.
Oralism - a method of educating the deaf that involves speech and speech reading. Does not incorporate
manual or signed communication.
Residual - amount of hearing a person has left after experiencing a hearing loss.
Tinnitus - buzzing, ringing, and other noises produced in the inner ear.
Unilateral Hearing Loss - hearing loss in one ear.
Vertigo - dizziness.
Types of Hearing Loss
Conductive Hearing Loss - damage or obstruction in the outer or middle ear blocks the sound waves.
Voices, noises, etc., may seem distorted, faint, or both.
Mixed Hearing Loss - a hearing loss caused by conductive and sensorineural factors.
Sensorineural Hearing Loss - “Nerve Deafness.” The signal cannot be properly delivered to the brain
because of damage or improper formation of the inner ear/auditory nerve.
Onset of Hearing Loss
Prelingual Hearing Loss - occurs before the acquisition of language (around age 3).
Pre-vocational Hearing Loss - occurs after age where spoken language normally is acquired (usually
before the age of 18). Affects of prevocational deafness depend on the individual and the duration of loss.
Post-vocational Hearing Loss - affects of prevocational deafness depend on the individual and the
duration of loss (usually after the age of 18).
48
APPENDIX B
Guidelines for Cochlear Implants*
(Approved by Leadership Council 5/6/97 and Updated as of December 2011)
An Overview of Cochlear Implants
Narrative originally written by Gary Cater, DO, VR Medical Consultant
*This section also provides codes and prior approval procedures for BAHA that are similar for cochlear
implants. The use of cochlear implantation is relatively new. Apparently, this option has been a
successful type of therapy for those with severe to profound sensorineural hearing loss, and for
those who are unable to be helped with conventional hearing aids. This small electronic device is surgically
implanted under the skin behind the ear. Sound waves enter the microphones, which are then sent to a
speech processor via a thin cable that can be worn on a belt or attached to behind-the-ear device (looks
like a hearing aid). The speech processor is a powerful miniature computer that translates incoming
sounds into distinct electrical codes. The speech signal is sent through the same cable, to the headpiece
and transmitted across the skin via radio waves to the implanted device. This signal then travels down to
the electrode array, which has been positioned within the inner ear and stimulates the auditory nerve. This
eventually is interpreted as meaningful sound
Those individuals who no longer have useful speech recognition, even with high-powered hearing aids can
benefit from a cochlear implant. Hearing aids simply amplify sound. The implant bypasses the damaged
parts of the inner ear and electrically stimulates the auditory nerve fibers in the cochlea. While it may take
some time, even months, most individuals in case studies develop successful auditory stimulation.
Originally, these implants were limited to individuals who were postlingually deafened adults and did not
have bony sclerosis of the cochlea. Recently, these devices have been approved for use in prelingually
deafened children. There have also been favorable results in adults with partial to near obliteration of their
cochleas.
The risks of cochlear implant surgery are no greater than those associated with any major ear surgery
requiring general anesthesia. As always there are some minor risks of temporary problems that do not
appear to be a significant contradiction.
The advanced technology that is now available has replaced the original single channel device with
multichannel implant devices. The user can switch among speech strategies to the one that provides the
optimal sound quality. Future strategies may be added with new computer software programs. This would
not require replacing either the implanted or the external components.
General Conclusions:



Etiology does not appear to effect auditory performance.
Individuals with shorter durations of auditory deprivation achieve better auditory performance from any
type of sensory aid, including a cochlear implant, than do individuals with longer duration deafness.
Cochlear implantation has a profound impact on post lingual deafened adults with success rates of
80-90% speech recognition. Results however, still show wide ranges of outcomes.
49



The vast majority of deaf adults with cochlear implants derive substantial benefit when the implant is
used with speech reading. Potential individuals must therefore be required to develop lip reading skills
and will attend training sessions for this purpose if necessary.
Because of the wide variability in speech perception and recognition in persons with similar hearing
loss, all candidates require counseling about the surgery, its risks and benefits and other alternatives to
surgery.
Individuals should understand that the large variability in individual performance precludes preoperative
predictions of success.
COCHLEAR IMPLANT CODES
PRE OPERATIVE CODES – AUDIOLOGY (RIMS Service Type: Physical Restoration)
925560 SPEECH DISCRIMINATION TESTING- The patient will undergo a series of speech perception
tests. Each test will be billed separately under this code. Approximately eight to ten tests are completed.
These tests include selected tests from the NIAC battery of speech discrimination tests;
Question/Statement Test, Vowel Discrimination Test, Noise/Voice Test, Accent Test, CID Everyday
Sentence Discrimination Test, Initial Consonant Discrimination Test. Additionally, Speech Tracking Tests
and Telephone Speech Discrimination Tests are administered. Speech perception testing is completed
pre-op, and at regular intervals post-op.
925570 HEARING EVALUATION - The patient is evaluated with and without hearing aids. In addition to a
hearing evaluation under headphones, each ear will need to be tested alone with a hearing aid,
and then both ears will need to be tested together with hearing aids. At least four tests will be
completed. If patient's hearing aids are determined to be inappropriate, testing with hearing aids
will be repeated with more appropriate hearing aid devices.
925670 TYMPANOMETRY - Test to check the integrity of the middle ear system. Assists in identifying
middle ear disease such as ear infections, Otosclerosis, ossicular chain discontinuity, and other
middle ear abnormalities.
925680 ACOUSTIC REFLEX TESTING - Acoustic Reflex Thresholds are measured at various frequencies
in an effort to determine whether hearing loss is conductive, sensory, neural, or sensorineural.
This test assists in determining the cause or site of the hearing loss.
925850 AUDITORY BRAINSTEM RESPONSE TESTING (ABR) - This test is used to determine the
integrity of the auditory neural pathways. Additionally, this test is often used to estimate hearing
thresholds in both children and adults.
925870 Evoked Otoacoustic Emissions – Single
925880 Evoked Otoacoustic Emissions – Comprehensive
925940 Electroacoustic Evaluation for one Hearing Aid
925950 Electroacoustic Evaluation for two Hearing Aids
926260 Evaluation of Auditory Rehabilitation Status; First Hour
927000 CI Counseling
977610 Prosthetic Training; Upper and Lower
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992040 MD Visit; New Patient 45 Minutes (codes may vary with different doctors; depending on
time)
704800 CT Scan (Without Contrast
905510 MRI, Brain (Without Contrast) – Not Done for Everyone
OPERATIVE CODES (RIMS Service Type: Physical Restoration)
697140 IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITHOUT
MASTOIDECTOMY (Surgery)
697150 IMPLANTATION, OSSEOINTEGRATED IMPLANT, TEMPORAL BONE, WITH
MASTOIDECTOMY (Surgery)
697170 REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), WITHOUT
MASTOIDECTOMY (Surgery)
697180 REPLACEMENT (INCLUDING REMOVAL OF EXISTING DEVICE), WITH
MASTOIDECTOMY (Surgery)
699300 COCHLEAR IMPLANT (Doctor Fee)
958670 Needle Electromyography
959200 Intraoperative Neurophysiology Testing; Per Hour
140220 Adjacent Tissue Transfer
CL8614 COCHLEAR DEVICE/SYSTEM (Install Device): RIMS Svs. Type: Prosthesis/Orthotics
Plus COST OF HOSPITALIZATION (RIMS Service Type: Hospitalization for per diem rates at
a particular hospital)
Plus: ANESTHESIA
POST OPERATIVE CODES – AUDIOLOGY (RIMS Service Type: Physical Restoration)
925070 TREATMENT OF SPEECH, LANGUAGE, VOICE, COMMUNICATION,
AND/OR AUDITORY PROCESSING DISORDER (including aural rehabilitation), Individual. (This
replaced old code 92510, and became effective on 03/01/03.)
925670 TYMPANOMETRY - Used in combination with 92568 and 97750 to set comfort limits in the speech
processor.
925680 ACOUSTIC REFLEX TESTING - Used in combination with 92567 and 97750 to set upper
comfort limits in the speech processor. This is to help insure that stimulation through the
processor is not too loud for the patient.
926030 DIAGNOSTIC ANALYSIS OF COCHLEAR IMPLANT, PATIENT 7 YEARS OR
OLDER WITH PROGRAMMING (This new code became effective on 03/01/03.)
926040 DIAGNOSITC ANALYSIS OF COCHLEAR IMPLANT, PATIENT 7 YEARS OR
OLDER WITH SUBSEQUENT RE-PROGRAMMING (This new code became effective
on 03/01.)
977500 Used in combination with 925670 and 925680 to set upper comfort limits in the
speech processor.
977610 PROSTHETIC TRAINING (Replaced 975200). Definition: Prosthetic training; upper
and/or lower extremity(ies), each 15 minutes. This includes showing the patient how
51
the equipment functions and instructions on how to use the device.
977620 PROSTHETIC CHECK OUT (Replaced 977030). Definition: Check out for
orthotic/prosthetic use; established patient, each 15 minutes. This code will be used
each time the patient is seen to check all the parts of the device for problems. If one or
any of the external components of the cochlear implant system is not functioning, the
patient will not hear from the device correctly. The audiologist check all of the external
equipment including Microphone, speech processor, coil/magnet device, and cords.
PARTS-REPAIR-REPLACEMENTS** (RIMS Service Type: Prosthesis/Orthotics)
C99701 Cochlear Implant (CI) Repair
C99702 CI Supplies and Materials
CL8615 Replace CI Headset
CL8616 Replace CI Microphone
CL8617 Replace CI Trans. Coil
CL8618 Replace CI Trans. Cable
CL8619 Replace Cochlear Processor
CL8620 Replace Lithium Ion Battery
CL8621 Replace Zinc Air Battery
CL8622 Replace Alkaline Battery
CL8623 Lithium Ion Battery CID, non ear level
CL8624 Lithium Ion Battery CID, ear level
OTHER OPTIONAL SERVICE CODES
697140 ImpltJ 01 Implt B1 B/O Mstdc
697150 ImpltJ 01 Implt B1 Mstdc
697170 Replacement 01 Implt B1 W/O Mstdc
697180 Replacement 01 Implt B1 Mstdc
925560 Speech Audiometry
**When purchasing CI Cords and related items from a physician, you can use code C99999 (Other
orthotic/prosthetic items not elsewhere listed). When purchasing CI Cords and related items from an
audiologist, you may face problems using code C99999 to pay for these as this code may be restricted to
physician vendors only so you may need to use Code 990700 instead.
Note: Original Pre/Post-Operative Audiology codes and descriptions were provided to Disability Examiners of America by Dr. Bartel
of Tampa.
PROCESS OF COCHLEAR IMPLANTATION
1. Pre-Operative Preparation
a. Evaluation of Hearing, Speech, Language, Voice, Communication, and/or Auditory Processing
b. Otolaryngologist visit
c. MAC Battery (speech discrimination tests)
d. Radiographic studies (CAT scan or x-rays) of the inner ear.
f. Other tests and/or services as required.
52
2. Implant Procedure
a. Hospital- (surgery) cost overall will be an overall per diem cost, which includes the implant
and any other services (e.g. CAT scan) that the individual needs while the individual is in
the hospital.
b. Anesthesiology
c. Doctor Fee for Surgery (Usually 699300)
d. Cochlear Implant Devices/System- the wearable speech processor and headset will not
be purchased while the individual is in the hospital. The otolaryngologist shall provide the
speech processor and headset for actual cost. The physician may not earn any profit
above and beyond the actual cost. (Fee Code CL8614) (Note: Some hospitals may
require VR to authorize purchase of the device directly from the hospital prior to surgery
and on a separate authorization for per diem – check with the hospital as to its procedures
relating to cochlear implants and devices)
e. Electromyography during Surgery (958670)
3. Post-Operative Activities
a. Audiological (Aural) Rehabilitation-Post-Surgery: post surgery stimulation,
programming, training, and counseling.
b. Speech Processor Programming & Therapy- up to 3 hours once a week for ten weeks,
for a total of 30 hours. Additional sessions beyond 30 hours will require prior approval.
c. Final Testing - follow-up visits at 6, 9 and 12 months
d. Other tests and/or services as required.
CONSUMER QUALIFICATIONS FOR COCHLEAR IMPLANTATION
The following qualifications are provided for DVR counselors when considering candidates for
cochlear implants:
1. The consumer must have severe or profound sensorineural hearing loss, and not be able to benefit
from any type of hearing aid.
2. The consumer must have post-lingual deafness, be of working age and have the potential to become
employable. Those with pre-lingual deafness must demonstrate ability to use speech for everyday
communication.
3. The consumer must not have any mental or medical condition that would preclude optimal use of the
cochlear implant such as: active middle ear infections, cochlear ossification that prevents electrode
insertion, absence of cochlear development, or tympanic membrane deformation.
4. The consumer must receive prior consultation concerning benefits and risks of the cochlear implant
and acknowledge the changes that may occur in one’s life as a result of this procedure.
5. The consumer shall agree to first explore outside resources including private insurance to cover any, if
not all, the costs of a cochlear implant before seeking Vocational Rehabilitation (VR) sponsorship.
6. The consumer, if qualified for cochlear implant, must agree to attend all scheduled rehabilitation
sessions, in addition to the initial programming of the speech processor following the recuperation
period after surgery.
53
PERSONNEL QUALIFICATIONS:
Physician – those involved in cochlear implant surgery must be a board certified otolaryngologist and on
the VR vendor list; must have at least 30 hours post-graduate training in cochlear implants.
Audiologist - those involved in cochlear implant case must be a certified audiologist with the American
Speech Language and Hearing Association and have at least 30 hours post-graduate training in cochlear
implants.
PAYMENT FOR COCHLEAR IMPLANT(S)
Division of Vocational Rehabilitation (DVR) will pay based on the following types of cases:

DVR sponsored:
o DVR will pay the hospital Medicaid per diem rate.
o DVR will pay $21,450 to $24,800 for the one cochlear implant device, using code CL8614.
The amount will vary from hospital to hospital.
o DVR will pay for doctor fees and pre and post operative services at the Medicare rate.
o If a second device and speech processor are recommended, DVR will require an
additional justification from the physician who specializes in cochlear implantation.

Medicaid recipient:
o Medicaid will pay for one implant.
o If two implants are required, DVR will pay for the second device, doctor fees and pre and
post operative services at the Medicare rate.
o If a second device and speech processor are recommended, DVR will require an
additional justification from the physician who specializes in cochlear implantation.

Medicare recipient:
o DVR will pay the deductibles and/or coinsurance that Medicare does not cover.

Private insurance recipient:
o DVR will pay the co-payment.
o If the third party only pays for one implant, DVR would pay for the second implant, doctor
fees and pre and post operative services at the Medicare rate.
o If a second device and speech processor are recommended, DVR will require an
additional justification from the physician who specializes in cochlear implantation.
Note: If a second device is justified, DVR will pay 50% using the modifier 50 (bilateral).
BAHA CODES
For BAHA, consult with the vendor on appropriate codes for surgery and device as some codes may be
similar to CI as listed under OPERATIVE CODES (physical restoration). There is no professional fee as
this device is not a hearing aid. For example: you may consider implantation fee code 958670 or 697140
plus hospitalization per-diem rate and other fees as required.
54
BAHA specific codes listed in RIMS under Prosthetics and Orthotics include the following:
CL8690 (internal and external components)
CL8691 (external component or sound processor: replacement only)
CL8689 (external recharging system – internal)
CL8695 (external recharging system – external)
CL9900 (miscellaneous orthotic or prosthetic component or device accessory) – this code
can only be used for purchasing the external component or speech processor
92700 (unlisted otohinolaryngolical service or device) – this code can cover professional
services including assessment, adjustment fitting, and dispensing sound
processor. (Physical Restoration Code)
CL8699 (prosthetic implant, not otherwise specified)
C97705 BAHA Repair (NEW)
55
State VR Prior Approval Checklist
For CI or BAHA Surgery/Implantation
VR Consumer:
VR#
All Cochlear Implantation (CI) and Bone Anchored Sound Processors (BAHA) require state prior
approval. Each individual case must first be reviewed with the area medical consultant. Requests for
approval then must be sent to the Bureau of Field Services at the State Vocational Rehabilitation (VR)
office. The requests will then be reviewed prior to authorization of CI or BAHA.
CI and BAHA speech/sound processor (external device) replacements or repairs do not require state prior
approval.
To obtain Prior Approval from State Office, forward the following documents as a package to the
Bureau Chief of Field Services, along with the State Level Prior Approval Template:
a) _____A narrative summary prepared by the counselor stating how the consumer will benefit, in terms
of employment, by receiving a cochlear implant or BAHA. Include the following: if one or two cochlear
implants are being recommended; if there are similar benefits; documentation of informed choice through
counseling & guidance with the consumer of this surgery, including but not limited to the benefits of a
cochlear implant & risks of surgery
b) _____ Copy of the evaluation reports from the audiologist (audiological, hearing aid and speech
evaluation with indication of individual’s lip-reading ability) and qualified otolaryngologist (ENT report) along
with radiographic studies of the cochlea stating that the consumer is a good candidate for the cochlear
implant (or BAHA) and surgery
c) _____ Copy of consultation report from the area medical consultant regarding the appropriateness of
the procedure and implications for the consumer’s vocational rehabilitation
d) _____ Copies of additional reports as required, such as GME, psychological and ophthalmological
and any supporting documentation that is not in the data system that the counselor feels is pertinent.
56