Original Notice.

     Preproposal statement of inquiry was filed as WSR 07-05-011.

     Title of Rule and Other Identifying Information: The department is repealing sections in chapter 388-544 WAC and creating a new chapter 388-547 WAC for hearing aids services.

     Hearing Location(s): Office Building 2, Auditorium, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or by calling (360) 664-6094), on March 10, 2009, at 10:00 a.m.

     Date of Intended Adoption: Not sooner than March 11, 2009.

     Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on March 10, 2009.

     Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by February 24, 2009, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at johnsjl4@dshs.wa.gov.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department is proposing the following changes to the hearing aids and services rules:

•	Repeal WAC 388-544-1010, 388-544-1100, 388-544-1200, 388-544-1300, and 388-544-1400;
•	Create new chapter 388-547 WAC, Hearing aids and services;
•	Separate criteria for adults and children within the chapter;
•	Define adults as twenty-one years of age and older and children as twenty years of age and younger;
•	Change the criteria for replacement of ear molds for adults to once a year regardless of whether they are soft or hard;
•	Add pocket talkers and similar devices to the noncovered list for adults;
•	Remove the prior authorization requirements for bone conduction hearing aids for adults;
•	Clarify eligibility requirements by adding the TAKE CHARGE program under the list of clients not eligible;
•	Remove the requirement that providers receive a stamped authorization approval from the local children with special health care needs (CSHCN) coordinator;
•	Remove digital and programmable hearing aids from the noncovered list;
•	Lower the average degree of hearing loss from 50 decibels (dBHL) to 45 decibels (dBHL); and
•	Clarify record requirements.

     Reasons Supporting Proposal: The intent of these proposed rule changes is to bring the hearing aids and services program in line with current industry standards as much as possible. Also, the department removed the cumbersome and costly prior authorization process for children as requested by its hearing aid providers; thus allowing quicker access to hearing aids and services for children. The department also lowered the average degree of hearing loss decibel requirement[s] which expands the availability of hearing aids to a larger population.

     Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

     Statute Being Implemented: RCW 74.08.090.

     Rule is not necessitated by federal law, federal or state court decision.

     Name of Proponent: Department of social and health services, governmental.

     Name of Agency Personnel Responsible for Drafting: Wendy Boedigheimer, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1306; Implementation and Enforcement: Jean Gowen, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-2005.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the rules and determined that no new costs will be imposed on small businesses or nonprofit organizations.

     A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Jean Gowen, Health and Recovery Services Administration, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-2005, fax (360) 586-9727.

January 29, 2009

Stephanie E. Schiller

Rules Coordinator

     (1) The department covers the hearing aid services listed in this chapter, according to department rules and subject to the limitations and requirements in this chapter.

     (2) The department pays for hearing aids and services when:

     (a) Covered. Refer to WAC 388-547-0400 for covered hearing aids and services for adults; and refer to WAC 388-547-0800 for covered hearing aids and services for children;

     (b) Within the scope of an eligible client's medical care program;

     (c) Medically necessary as defined under WAC 388-500-0005;

     (d) Authorized, as required within this chapter, chapters 388-501 and 388-502 WAC, and the department's published billing instructions and numbered memoranda;

     (e) Billed according to this chapter, chapters 388-501 and 388-502, and the department's published billing instructions and numbered memoranda; and

     (f) The client:

     (i) Completes a hearing evaluation, including an audiogram performed and/or interpreted by a hearing healthcare professional;

     (ii) Has an average degree of hearing loss at forty-five decibels (dBHL) in the better ear based on a pure-tone audiometric evaluation by a licensed audiologist or licensed hearing instrument fitter/dispenser at one thousand, two thousand, three thousand, and four thousand Hertz (Hz) with effective masking as indicated; and

     (iii) Is referred by a hearing healthcare professional for a hearing aid.

     (3) The department requires prior authorization for covered hearing aid services when the clinical criteria set forth in this chapter are not met. The department evaluates these requests on a case-by-case basis to determine whether they are medically necessary, according to the process found in WAC 388-501-0165.

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     "FM systems" - Devices used to improve and augment access to auditory information in poor acoustic conditions (helps mitigate a negative impact of noise and reverberation on the ability to understand) that are found in classrooms, auditoriums, theaters, restaurants, etc. These devices use frequency modulated (FM) radio signals to transmit the primary auditory signal from a microphone/transmitter to a receiver worn by the person.

     "Hearing aids" - Wearable sound-amplifying devices that are intended to compensate for hearing loss. Hearing aids are described by where they are worn in the ear as In-the-Ear (ITE), Behind-the-Ear (BTE), etc. Hearing aids can also be described by how they process the amplified signal. This would include analog conventional, analog programmable, digital conventional, and digital programmable.

     "Hearing healthcare professional" - An audiologist or hearing aid fitter/dispenser licensed under chapter 18.35 RCW, or an otorhinolaryngologist or otologist licensed under chapter 18.71 RCW.

     "Maximum allowable fee" - The maximum dollar amount that the department will pay a provider for specific services, supplies and equipment.

     "Prior authorization" - A form of authorization used by the provider to obtain approval for a specific hearing aid and service(s). The approval is based on medical necessity and must be received before the service(s) are provided to clients as a precondition for payment.

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     (a) A categorically needy (CN) medicaid program; or

     (b) General assistance (GAU/ADATSA) (within Washington state and designated border cities.

     (2) Clients who are enrolled in a department-contracted managed care plan are eligible under fee-for-service for covered hearing aid services that are not covered by their plan, subject to the provisions of this chapter and other applicable WAC.

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     (1) One new, nonrefurbished, monaural hearing aid, which includes the ear mold, for an adult client every five years when the hearing aid meets the client's specific hearing needs and is under warranty for a minimum of one year.

     (2) One replacement hearing aid, which includes the ear mold, in a five year period when the client's hearing aid(s) is lost or beyond repair and all warranties are expired.

     (3) A replacement ear mold once a year when the client's existing ear mold is damaged or no longer fits the client's ear.

     (4) A maximum of two repairs, per hearing aid, per year, when the repair is cost effective as determined by the department. To receive payment, all of the following must be met:

     (a) All warranties are expired; and

     (b) The repair is under warranty for a minimum of ninety days.

     (5) Rental hearing aid(s) for up to two months while the client's own hearing aid is being repaired.

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     (1) Batteries;

     (2) Tinnitus maskers;

     (3) FM systems; or

     (4) Pocket talkers or similar devices.

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     (2) The department evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 388-501-0169.

     (3) To request prior authorization from the department, a provider must fax the prior authorization request to the department using the appropriate fax number listed in published hearing aid services billing instructions.

     (4) When the department authorizes hearing aids and/or services, the prior authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The client must be eligible for covered services at the time those services are provided.

     (5) To receive payment, hearing aids and/or services must be ordered and dispensed within the authorized timeframe.

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     (a) Are eligible for covered hearing aids and services under this chapter and for the audiology services under WAC 388-545-0700;

     (b) Must have a complete hearing evaluation, including an audiogram performed by a hearing healthcare professional; and

     (c) Must be referred by a licensed audiologist, otorhinolaryngologist or otologist for a hearing aid.

     (2) Clients eighteen through twenty years of age must have a referral by a screening provider under the early and periodic screening, diagnosis, and treatment (EPSDT) program.

     (3) Clients who are enrolled in a department-contracted managed care plan are eligible under fee-for-service for covered hearing aid services that are not covered by their plan, subject to the provisions of this chapter and other applicable WAC.

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     (2) The department pays for:

     (a) Replacement hearing aid(s), which includes the ear mold, for children when:

     (i) The client's hearing aid(s) are:

     (A) Lost;

     (B) Beyond repair; or

     (C) Not sufficient for the client's hearing loss; and

     (ii) All warranties are expired.

     (b) Replacement ear mold(s) when the client's existing ear mold is damaged or no longer fits the client's ear.

     (c) A maximum of two repairs, per hearing aid, per year, when the department determines it is cost effective to repair. To receive payment, all of the following must be met:

     (i) All warranties are expired; and

     (ii) The repair is under warranty for a minimum of ninety days.

     (d) A rental hearing aid(s) for up to two months while the client's own hearing aid is being repaired.

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     (a) Batteries or tinnitus maskers;

     (b) Group screenings for hearing loss, except as provided under the early and periodic screening, diagnosis and treatment (EPSDT) program under WAC 388-534-0100; or

     (c) Computer-aided hearing devices for FM systems used in school.

     (2) When EPSDT applies, the department evaluates a noncovered service, equipment, or supply according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 388-534-0100 for EPSDT rules).

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     (2) The department evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 388-501-0169.

     (3) To request prior authorization from the department, a provider must fax the prior authorization request to the department using the appropriate fax number listed in the department's published hearing aid services billing instructions.

     (4) When the department authorizes hearing aids and/or services the prior authorization indicates only that the specific service is medically necessary; it is not a guarantee of payment. The client must be eligible for covered services at the time those services are provided.

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     (a) A prefitting evaluation;

     (b) An ear mold; and

     (c) A minimum of three post-fitting consultations.

     (2) The department denies payment for hearing aids and/or services when claims are submitted without the required prior authorization number or the appropriate diagnosis or procedure code(s).

     (3) The department does not pay for hearing aid charges paid by insurance or other payer source.

     (4) To receive payment, the provider must keep documentation in the client's medical file to support the medical necessity for the specific make and model of the hearing aid ordered for the client. This documentation must include the record of the audiology testing providing evidence that the client's hearing loss meets the eligibility criteria for a hearing aid.

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     The following sections of the Washington Administrative Code are repealed:

WAC 388-544-1010	Definitions.
WAC 388-544-1100	Hearing aid services -- General.
WAC 388-544-1200	Hearing aid services -- For adults.
WAC 388-544-1300	Hearing aid services -- For children.
WAC 388-544-1400	Hearing aid services -- Noncovered services.

© Washington State Code Reviser's Office