In April 2019, the American Academy of Audiology (Academy) and the American Speech–Language–Hearing Association (ASHA), released the document Suggested Best Practices for Audiologists’ Determination of Need for Captioned Phone Services. The two organizations drafted this document in response to concerns identified by the Federal Communications Commission (FCC) that the captioned telephone services (CTS) program is being overused, which could lead to potential funding deficits for this important service. The document outlines nine recommended best practices to offer guidance to audiologists when determining if the captioned telephone is an effective option for a patient.

The Academy was pleased to work with ASHA on developing the project, as well as eliciting the insights of many members and other stakeholders in shaping the suggested best practices. Stakeholders included the Hearing Loss Association of America (HLAA), which provided a critical review of the document and offered valuable enhancements to clarify the description of the CTS program.

We are providing here the complete document that was sent to the FCC and also posted on the ASHA and Academy websites.

Suggested Best Practices for Audiologists’ Determination of Need for Captioned Phone Services

Prepared by American Academy of Audiology and American Speech-Language-Hearing Association


Captioned telephone services (CTS) are designed to assist persons with hearing loss to place and receive telephone calls. CTS allow a person with hearing loss to speak directly to the called party and then listen and concurrently read captions of what the other party is saying. This service is important, as phone conversations can be difficult for persons who are deaf and hard of hearing because of their hearing loss and due to the reduced bandwidth of conventional phone systems. The loss of visual and contextual cues to supplement the auditory channel information further intensifies the difficulty experienced by the persons who are deaf and hard of hearing. As such, the challenge of using phones can be one of the factors that increases the isolation of persons with hearing loss, negatively impacts job and educational opportunities, employment, and safety.

CTS is a state and federally funded program that is provided free of charge to persons with hearing loss. CTS is financed through telephone bill surcharges paid by consumers to the phone companies, who pass those surcharge monies to the Telecommunications Relay Service (TRS) fund. The program is administered by the Federal Communications Commission. 

CTS is provided free of charge to persons with hearing loss. In addition to CTS, the FCC also pays for other communication services, including video relay service (VRS), IP Relay service, speech-to-speech relay service, and text-to-voice (TTY; text telephone) relay services. Under the Americans with Disabilities Act (ADA), these services are offered free of charge to people who are deaf or hard of hearing. 

The FCC compensates TRS providers for the cost of these services through disbursements from the TRS fund. TRS is currently available in all 50 states, Puerto Rico, and other U.S. territories.

Analog CTS is a landline-based service available over conventional phone lines. Analog CTS provides captions only on outgoing calls. The user must purchase a second phone line to have direct access to both incoming and outgoing CTS. If the user has only one landline number, the user must alert those calling in to use 711 to connect to CTS.

Specialized captioned phones are typically offered for free from the providers, but can also be purchased directly from the providers, through local retailers, the Internet, or, in some cases, consumers can qualify for special state programs where they can obtain a captioned phone at a reduced rate or for free.

The Internet Protocol Captioned Telephone Service (IP CTS) is an Internet-based system that uses an existing voice telephone and a computer, or other Internet connected device, rather than the conventional phone network, to provide the link and captions between the individuals who are deaf or hard of hearing and another party. IP CTS also can be used as an app with a smart phone. 

In the most widely-used version of IP CTS, when an IP CTS user places a call over the CTS, the call is automatically connected both to the receiving party and via the Internet to a communications assistant (CA). The CA hears and repeats everything the other party says, and voice-recognition software transcribes those words from the CA’s voice into text, which is then transmitted directly to the phone of the person with hearing loss. Currently, one of the providers of IP CTS is app-based only and uses CART writers to provide the text.

IP CTS allows deaf and hard-of-hearing persons to use contemporary communication technologies for more effective telephone use. The IP CTS was approved by the FCC as a form of relay service in 2007. The FCC has ruled that IP CTS calls are an approved form of TRS that may be compensated from the Interstate TRS Fund.

Anyone with hearing loss of sufficient degree that compromises successful use of a conventional telephone may be eligible for captioned phone service. For the landline-based analog CTS, the rules for eligibility vary from state to state, but most eligibility rules generally note that the individuals with hearing loss must personally certify that they require use of CTS, or they must obtain a certification form signed by a hearing-care provider (e.g., audiologist, primary care physician, hearing aid dispenser, or otolaryngologist among others). For IP CTS, a rulemaking by the FCC is underway to determine eligibility standards.

FCC regulations prohibit the use of CTS by people who do not have a hearing loss. This includes the use of this service by persons with no hearing loss who reside in the same household of the person with hearing loss. The use of CTS by individuals who have the capability of using conventional phone systems unnecessarily increases the cost of providing the TRS programs.

The American Academy of Audiology and the American Speech–Language–Hearing Association support the availability of CTS, including IP CTS, to allow individuals who have the degree, type, or configuration that prevents traditional telephone use, to still be able to access telephone services. These same organizations also understand the necessity to restrict this service only to persons who are deaf or hard of hearing and support efforts to reduce the use of the service by those who do not have hearing loss in order to preserve the service.


The Academy, Academy of Doctors of Audiology (ADA), and the American Speech-Language-Hearing Association (ASHA) have worked together to develop joint legislation that will expand benefits for millions of Medicare beneficiaries who may need audiologist services. 

The three organizations have garnered bipartisan congressional support for a bill that will offer direct access to both diagnostic and therapeutic services of audiologists. The Academy’s Government Relations Committee (GRC) encourages members to join the Grassroots Advocacy Network and to visit the Academy website for updates about the legislation and for guidance on how to engage in the advocacy efforts to advance the bill. The GRC will keep the Academy membership apprised of the progress with the bill.

Suggested Best Practices

It is incumbent upon the audiologist to assure that only those individuals who qualify for captioned service are so certified. As such, the following suggested best practices have been developed:

Individuals seeking CTS should have communication impairment that significantly affects speech understanding, even when using amplification devices and a conventional phone.

Individuals being considered for CTS should undergo an appropriate, comprehensive assessment to determine the need for assistive communication technologies, including CTS.

The patient history should include questions designed to determine the disability associated with telephone use and the availability of existing telephone technologies (e.g., smartphone, visual communication options such as FaceTime, availability of amplified systems, etc.), and desired patient outcomes.

The patient assessment should include procedures designed to determine need for assistive technologies, including CTS. This assessment may include, but not be limited to, auditory, visual, dexterity, physical and/or cognitive function. Additionally, the appropriate technological options available to the patient should  be considered.

Should the assessment determine that the patient would benefit from a captioned telephone, patients should be presented with the range of technological options available to enhance the ability to communicate via the telephone, including modifications to their own phone system or an amplified telephone.

Only people who are deaf or hard of hearing who are unable to use conventional phone services should be certified by a qualified hearing health-care provider for CTS.

Patients should be presented with options of CTS phone types, including both landline and smartphone apps, and the different providers whose phones offer different features, as well as the respective state agencies that may provide phones at a reduced fee.

Results of the assessment and clinical decision making that leads to a recommendation for CTS should be documented in the patient chart.

Hearing-care providers should not have a conflict of interest with respect to the relationship with CTS device providers. A conflict of interest is defined as a financial or personal interest that could unduly influence, or could appear to influence, decisions related to a primary interest such as patient care, student education, or validity of research.