WSR 11-07-076

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)

[ Filed March 22, 2011, 10:23 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 10-20-160.

Title of Rule and Other Identifying Information: Chapter 388-547 WAC, Hearing aids.

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 April 26, 2011, at 10:00 a.m.

Date of Intended Adoption: Not sooner than April 27, 2011.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery Office Building 2, DSHS Headquarters, 1115 Washington, Olympia, WA 98504, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on April 26, 2011.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by April 5, 2011, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at jennisha.johnson@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department of social and health services' medicaid purchasing administration (MPA) is adopting amendments to chapter 388-547 WAC, Hearing aids. Amendments to the hearing aids chapter are required upon order of the governor to reduce budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent. To achieve this expenditure reduction, MPA eliminated the following optional medical service(s) for adults twenty-one years of age and older effective January 1, 2011: Hearing devices to include hearing aids, bone anchored hearing aids (BAHA), cochlear implants, and parts, and batteries for such equipment including repairs.

Reasons Supporting Proposal: Governor Gregoire issued Executive Order 10-04 on September 13, 2010, under the authority of RCW 43.88.110(7). In the executive order, the governor required DSHS and all other state agencies to reduce their expenditures in state fiscal year 2011 by approximately 6.3 percent. As a consequence of the executive order, funding will no longer be available as of January 1, 2011, for the benefits that are being eliminated as part of these regulatory amendments.

Statutory Authority for Adoption: RCW 74.08.090.

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, medicaid purchasing administration, governmental.

Name of Agency Personnel Responsible for Drafting: Wendy L. Boedigheimer, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1306; Implementation and Enforcement: Ellen Silverman, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1570.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule amendments and determined that there are no new costs associated with these changes and they do not impose disproportionate costs on small businesses.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Ellen Silverman, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1570, fax (360) 586-9727, e-mail Ellen.Silverman@dshs.wa.gov.

March 18, 2011

Katherine I. Vasquez

Rules Coordinator

4254.5
AMENDATORY SECTION(Amending WSR 09-12-034, filed 5/27/09, effective 7/1/09)

WAC 388-547-0100   Hearing aids--General--For clients twenty-years of age and younger.   Unless otherwise defined in WAC 388-547-0200, the terms within this chapter are intended to correspond with the terms in chapter 18.35 RCW.

(1) The department covers the hearing aids ((services)) listed in this chapter, according to department rules and subject to the limitations and requirements in this chapter. See also WAC 388-531-0375 audiology services.

(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 clients twenty-one years of age and older; and refer to WAC 388-547-0800 for covered hearing aids and services for clients twenty years of age and younger));

(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; and

(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))) is twenty years of age or younger and completes a hearing evaluation, including an audiogram and/or developmentally appropriate diagnostic physiologic test results performed and/or interpreted by a hearing healthcare professional((;

(ii) Is referred by a hearing healthcare professional for a hearing aid; and

(iii) For clients twenty-one years of age and older only, 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)).

(3) The department requires prior authorization for covered hearing aids ((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.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 09-12-034, 388-547-0100, filed 5/27/09, effective 7/1/09.]


AMENDATORY SECTION(Amending WSR 09-12-034, filed 5/27/09, effective 7/1/09)

WAC 388-547-0700   Hearing aids--Eligibility--Clients twenty years of age and younger.   (1) Clients twenty years of age and younger who are receiving services under ((any)) a medical assistance program((, except for the family planning only program and the TAKE CHARGE program)):

(a) Are eligible for covered hearing aids ((and services)) under this chapter and for the audiology services under WAC ((388-545-0700)) 388-531-0375;

(b) Must have a complete hearing evaluation, including an audiogram and/or developmentally appropriate diagnostic physiologic test results performed by a hearing healthcare professional; and

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

(2) Clients who are enrolled in a department-contracted managed care ((plan)) organization (MCO) 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. However, clients enrolled in a department-contracted MCO must obtain replacement parts for cochlear implants and bone anchored hearing aids (BAHA) through their MCO.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 09-12-034, 388-547-0700, filed 5/27/09, effective 7/1/09.]


AMENDATORY SECTION(Amending WSR 09-12-034, filed 5/27/09, effective 7/1/09)

WAC 388-547-0800   Hearing aids--((Covered services))Coverage--Clients twenty years of age and younger.   (1) The department covers new, nonrefurbished, monaural or binaural hearing aid(s), which includes the ear mold, for eligible clients twenty years of age and younger. In order for the provider to receive payment, the hearing aid must meet the client's specific hearing needs and be under warranty for a minimum of one year.

(2) The department pays for the following replacements as long as the need for replacement is not due to the client's carelessness, negligence, recklessness, or misuse in accordance with WAC 388-501-0050(8):

(a) ((Replacement)) Hearing aid(s), which includes the ear mold, 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))) (3) The department pays for repairs as follows:

(a) A maximum of two repairs, per hearing aid, per year, when the repair is less than fifty percent of the cost of a new hearing aid. 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))) (b) A rental hearing aid(s) for up to two months while the client's own hearing aid is being repaired. In the case of a rental hearing aid(s), the department pays separately for an ear mold(s).

(4) The department pays for unilateral cochlear implant and osseointegrated hearing aids (BAHA) replacement parts when:

(a) The manufacturer's warranty has expired;

(b) The part is for immediate use, not a back-up part;

(c) The part needs to be replaced due to normal wear and tear and is not related to misuse or abuse of the item (see WAC 388-502-0160); and

(d) The part is not an external speech processor.

(5) The department covers for one cochlear implant external speech processor, including maintenance and repair.

(6) The department covers one BAHA speech processor, including maintenance and repair.

[Statutory Authority: RCW 74.08.090 and 74.09.530. 09-12-034, 388-547-0800, filed 5/27/09, effective 7/1/09.]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-547-0300 Hearing aids--Eligibility--Clients twenty-one years of age and older.
WAC 388-547-0400 Hearing aids--Covered services--Clients twenty-one years of age and older.
WAC 388-547-0500 Hearing aids--Noncovered services--Clients twenty-one years of age and older.
WAC 388-547-0600 Hearing aids--Prior authorization--Clients twenty-one years of age and older.

Washington State Code Reviser's Office