WSR 11-11-015

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)

[ Filed May 9, 2011, 8:48 a.m. , effective June 9, 2011 ]


Effective Date of Rule: Thirty-one days after filing.

Purpose: Upon order of the governor, the medicaid purchasing administration (MPA) must reduce its budget expenditures for the current fiscal year ending June 30, 2011, by 6.3 percent. To achieve this expenditure reduction, MPA is eliminating the following optional medical service(s) for adults twenty-one years of age and older: Hearing devices to include hearing aids, bone anchored hearing aids (BAHA), cochlear implants, and parts and batteries for such equipment, including repairs.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-547-0300, 388-547-0400, 388-547-0500 and 388-547-0600; and amending WAC 388-547-0100, 388-547-0700, and 388-547-0800.

Statutory Authority for Adoption: RCW 74.08.090.

Adopted under notice filed as WSR 11-07-076 on March 22, 2011.

A final cost-benefit analysis is available 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.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 3, Repealed 4.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 3, Repealed 4.

Date Adopted: May 9, 2011.

Susan N. Dreyfus

Secretary

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