Mo. Code Regs. tit. 13 § 70-45.010

Current through Register Vol. 49, No. 23, December 2, 2024

Section 13 CSR 70-45.010 - Hearing Aid Program

PURPOSE: This amendment clarifies participants that are eligible to receive hearing aid services and removes criteria that are no longer applicable or are outdated.

(1) Administration. The Hearing Aid Program shall be administered by the Department of Social Services, MO HealthNet Division. The services and items covered and not covered, the program limitations, and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO HealthNet Division through the hearing aid manual which is incorporated by reference and made a part of this rule, as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at dss.mo.gov/mhd, May 13, 2020. This rule does not incorporate any subsequent amendments or additions.

(2) Participants Eligible. The MO HealthNet Program pays for approved MO HealthNet services for hearing aid services when furnished within the provider's scope of practice to MO HealthNet eligible participants under the age of 21 or participants receiving MO HealthNet under a category of assistance for pregnant women, blind participants, or skilled nursing facility residents. The participant must be eligible on the date the service is furnished. Participants may have specific limitations for hearing aid services according to the type of assistance for which they have been determined eligible. It is the provider's responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the provider program manual. The provider shall ascertain the patient's MO HealthNet and managed care or other lock-in status before any service is performed. The participant's eligibility shall be verified in accordance with methodology outlined in the hearing aid manual.

(3) Prior Authorization of Hearing Aids. All hearing aids and related services require prior authorization with the exception of hearing evaluation for the purpose of prescribing a hearing aid, post-fitting evaluations, post-fitting adjustments, repairs to hearing aids no longer under warranty, and special tests for ruling out retro-cochlear involvement. All hearing aid program services provided to participants in nursing facilities require prior authorization.

(4) Hearing Evaluation Requirements. A hearing evaluation for the purpose of obtaining a hearing aid must be performed by an audiologist, hearing instrument specialist, or physician (MD or DO) prior to the submission of a Prior Authorization Request form. This testing, when administered for the purpose of prescribing a hearing aid, will be reimbursed by the MO HealthNet program. Testing performed in relation to a medical or surgical diagnosis or treatment for hearing deficits or related medical problems for purposes other than determining the need for a hearing aid is a noncovered service and is not reimbursable by the MO HealthNet Hearing Aid Program. The hearing evaluation performed for the purpose of obtaining a hearing aid must include, at a minimum, air conduction thresholds, bone conduction thresholds (with masking when necessary), speech reception thresholds and speech discrimination scores. The results obtained from these basic hearing tests must be clear and internally consistent, and must demonstrate that a hearing aid is needed, that it will benefit the participant and will support the recommendation of which ear is to be fitted. Testing must be provided in accordance with sound professional practice and the standards under which the provider is licensed.

(5) Hearing Loss (HL) Requirement. A participant's pure-tone average (PTA) must be thirty decibels (30dB) HL or greater in the better ear to qualify for a hearing aid. The PTA is the average air-conduction threshold for five hundred (500), one thousand (1,000), and two thousand (2,000) Hertz (Hz) measured with an earphone. Word recognition must be tested with a minimum of twenty-five (25) phonetically balanced word lists.

(6) Medical Ear Examination Requirements. The participant must receive a medical ear examination for pathology or disease by a physician licensed as an MD or DO. The medical ear examination must be performed within six (6) months prior to the date a hearing aid is dispensed.

(7) Obtaining and Fitting the Aid. Only after receipt of an approved Prior Authorization Request form should the provider proceed with the fitting and dispensing of the hearing aid.

(8) Post-fitting Evaluation. A post-fitting evaluation will be performed no sooner than fourteen (14) days or later than thirty (30) days after the hearing aid is dispensed. If the hearing aid is not providing adequate and substantial correction of the loss, reimbursement will not be made for the hearing aid.

(9) Reimbursement for Hearing Aids and Related Services. Payment will be made for each unit of service or item provided in accordance with the fee schedule determined by the MO HealthNet Division. Providers must bill their costs for the hearing aids. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider's billed charge.

(10) Services/Items Provided in a Nursing Home. A request for hearing evaluation for the purpose of prescribing a hearing aid must originate with the participant and must proceed with the participant's full knowledge and consent. All hearing aids and related services performed or provided in a nursing home, boarding home, domiciliary home, or institution require prior authorization as specified in section (3), with the exception that hearing evaluation for the purpose of prescribing a hearing aid being performed in these places of service also requires prior authorization.

(11) Binaural Hearing Aids. Binaural hearing aids may be covered by MO HealthNet if medically necessary and if prescribed by an otolaryngologist, otologist, or otorhinolaryngologist.

(12) Replacement Hearing Aids. Prior authorization may be granted for a second hearing aid within four (4) years if the first hearing aid was lost, destroyed, or ceased to function effectively and cannot be repaired.

(13) Hearing Aid Repairs. MO HealthNet covers necessary repairs to any eligible participant's hearing aid that is no longer under warranty. The warranty period on new hearing aids or repairs will be for one (1) year from the date the hearing aid is dispensed. The methods of reimbursement for repairs are as follows:

(A) Out-of-shop Repairs. Necessary repairs made out-of-shop, where the hearing aid must be sent out to the manufacturer or repair lab, will be reimbursed at twenty dollars ($20) plus the invoiced cost of the repair. The twenty dollars ($20) covers the provider's cost for postage and processing. Included also is any postage for returning the hearing aid to the provider, any insurance fee charged and a six- (6-) month warranty; and

(B) In-shop Repairs. Necessary repairs made in-shop will be reimbursed at the provider's cost for parts plus a reasonable charge for labor. The state consultant will determine the reasonable charge for labor. Repairs will be considered as in-shop repairs for-

1. Any repair made in the provider's office;

2. Any repair made in a provider-owned and/or operated repair or manufacturing lab; or

3. Any repair made by a provider who is employed by or affiliated with another provider who owns or operates a repair or manufacturing lab.

(14) Post-fitting Adjustments. A maximum of three (3) post-fitting adjustments or hearing aid repairs or any combination totaling three (3) are covered in a twelve- (12-) month period. Minor adjustments and repairs such as the following must be billed as a post-fitting adjustment:

(A) Reprogramming or adjusting the frequency response of the hearing aid;

(B) Modifying an earmold;

(C) Checking that the ear, earmold, and tubing are not occluded with ear wax;

(D) Removing of ear wax from the earmold and tubing;

(E) Venting earmold or closing vent;

(F) Adjusting maximum power output;

(G) Reinstructing the patient in the use and care of the hearing aid;

(H) Changing microphone filters or receivers;

(I) Conducting hearing retests;

(J) Evaluating the electroacoustic hearing aid; or

(K) Cleaning the hearing aid.

(15) Basic Program Limitations. Benefits under the hearing aid program are limited by the following:

(A) A participant is entitled to one (1) new hearing aid and related services (testing, earmold, fitting, dispensing, and post-fitting evaluation) per four (4) years;

(B) Backup or spare hearing aids are non-covered regardless of when the first hearing aid was dispensed:

(C) Any hearing aid for the purpose of binaural amplification must be prescribed by an otolaryngologist, otologist or otorhinolaryngol-ogist;

(D) All repairs for hearing aids must include a six (6)-month warranty;

(E) MO HealthNet will not reimburse for repairs to a hearing aid that is five (5) years of age or older; and

(F) A new hearing aid will not be purchased within six (6) months of the repair of an old hearing aid.

(16) Records Retention. The MO HealthNet Division may impose sanctions against a provider for failing to make available, and disclosing to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO HealthNet records in compliance with 13 CSR 70-3.030. Providers must retain these records for six (6) years from the date of service. Fiscal and medical records coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal, or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation.

13 CSR 70-45.010

AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp. 2013. This rule was previously filed as 13 CSR 40-81.120. Emergency rule filed June 1, 1979, effective June 11, 1979, expired Sept. 13, 1979. Original rule filed June 1, 1979, effective Sept. 14, 1979. For intervening history, please consult the Code of State Regulations. Amended: Filed Oct. 10, 2013, effective Apr 30, 2014.

Amended by Missouri Register October 15, 2020/Volume 45, Number 20, effective 11/30/2020