WSR 13-20-013 PERMANENT RULES HEALTH CARE AUTHORITY (Medicaid Program) [Filed September 20, 2013, 12:00 p.m., effective October 21, 2013]
Effective Date of Rule: Thirty-one days after filing.
Purpose: The agency is revising these rules to:
1. Remove batteries from noncovered and add them to covered;
2. Clarify that FM systems, including the computer-aided hearing devices for FM systems are not covered unless the agency grants a request for an exception to rule allowing payment of the noncovered service; and
3. Make housekeeping fixes such as correcting WAC citations, cross references, and changing department to agency.
Citation of Existing Rules Affected by this Order: Amending WAC 182-547-0100, 182-547-0200, 182-547-0700, 182-547-0800, 182-547-0900, 182-547-1000, and 182-547-1100.
Statutory Authority for Adoption: RCW 41.05.021.
Adopted under notice filed as WSR 13-15-071 on July 16, 2013.
Changes Other than Editing from Proposed to Adopted Version: WAC 182-547-0100 Hearing aids—General—For clients twenty years of age and younger. Housekeeping fix. The agency unstruck the term "billing instructions" throughout and removed the proposed language "medicaid provider guides." The general term ["]billing instructions["] is still accurate (even though the actual name of the documents have changed to "medicaid provider guide"). To avoid confusion, the agency is keeping the general term "billing instructions" throughout.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 7, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 7, Repealed 0.
Date Adopted: September 20, 2013.
Kevin M. Sullivan
Rules Coordinator
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-547-0100 Hearing aids—General—For clients twenty years of age and younger.
Unless otherwise defined in WAC ((388-547-0200)) 182-547-0200, the terms within this chapter are intended to correspond with the terms in chapter 18.35 RCW. (1) The ((department)) agency covers the hearing aids listed in this chapter, according to ((department)) agency rules and subject to the limitations and requirements in this chapter. See also WAC ((388-531-0375)) 182-531-0375 audiology services. (2) The ((department)) agency pays for hearing aids when: (a) Covered; (b) Within the scope of an eligible client's medical care program; (c) Medically necessary as defined under WAC ((388-500-0005)) 182-500-0070; (d) Authorized, as required within this chapter, chapters ((388-501)) 182-501 and ((388-502)) 182-502 WAC, and the ((department's)) agency's published billing instructions and ((numbered memoranda)) provider notices; ((and)) (e) Billed according to this chapter, chapters ((388-501)) 182-501 and ((388-502)) 182-502, and the ((department's)) agency's published billing instructions and ((numbered memoranda)) provider notices; and (f) The client 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 health care professional. (3) The ((department)) agency requires prior authorization for covered hearing aids when the clinical criteria set forth in this chapter are not met. The ((department)) agency 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)) 182-501-0165.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-547-0200 Hearing aids—Definitions.
The following definitions and those found in chapter 182-500 WAC apply to this chapter. "Digital hearing aids" - Hearing aids that use a digital circuit to analyze and process sound. (("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 health care 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)) agency 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.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-547-0700 Hearing aids—Eligibility—Clients twenty years of age and younger.
(1) Clients twenty years of age and younger who are receiving services under a medical assistance program: (a) Are eligible for covered hearing aids under this chapter and for the audiology services under WAC ((388-531-0375)) 182-531-0375; (b) Must have a complete hearing evaluation, including an audiogram and/or developmentally appropriate diagnostic physiologic test results performed by a hearing health care 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)) an agency-contracted managed care 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)) an agency-contracted MCO must obtain replacement parts for cochlear implants and bone anchored hearing aids (BAHA), including batteries, through their MCO.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-547-0800 Hearing aids—Coverage—Clients twenty years of age and younger.
(1) The ((department)) agency 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)) agency 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))) 182-501-0050(8): (a) 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) Ear mold(s) when the client's existing ear mold is damaged or no longer fits the client's ear. (3) The ((department)) agency 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. (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)) agency pays separately for an ear mold(s). (4) The ((department)) agency 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)) 182-502-0160); and (d) The part is not an external speech processor. (5) The ((department)) agency covers ((for)) one cochlear implant external speech processor, including maintenance and repair. (6) The ((department)) agency covers one BAHA speech processor, including maintenance and repair. (7) The agency covers batteries for hearing aids, cochlear implant external speech processors, and BAHA speech processors.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-547-0900 Hearing aids—Noncovered services—Clients twenty years of age and younger.
(1) The ((department)) agency does not cover the following hearing and hearing aid-related items and services for clients twenty years of age and younger: (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)) 182-534-0100; or (c) FM systems, including the computer-aided hearing devices for FM systems ((used in school)). (2) When EPSDT applies, the ((department)) agency evaluates a noncovered service, equipment, or supply according to the process in WAC ((388-501-0165)) 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC ((388-534-0100)) 182-534-0100 for EPSDT rules).
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-547-1000 Hearing aids—Prior authorization—Clients twenty years of age and younger.
(1) Prior authorization is not required for clients twenty years of age and under for hearing aid(s) and services. Providers should send claims for clients twenty years of age and younger directly to the ((department)) agency. Providers do not have to obtain authorization from the local children with special health care needs (CSHCN) coordinator. (2) The ((department)) agency 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)) 182-501-0169.
AMENDATORY SECTION (Amending WSR 11-14-075, filed 6/30/11, effective 7/1/11)
WAC 182-547-1100 Hearing aids—Reimbursement—General.
(1) The ((department's)) agency's payment for purchased hearing aids includes: (a) A prefitting evaluation; (b) An ear mold; and (c) A minimum of three post-fitting consultations. (2) The ((department)) agency denies payment for hearing aids and/or services when claims are submitted without the prior authorization number, when required, or the appropriate diagnosis or procedure code(s). (3) The ((department)) agency 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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