((Unless otherwise defined in WAC 182-547-0200, the terms within this chapter are intended to correspond with the terms in chapter 18.35 RCW.))

(1) The medicaid agency covers the hearing aids listed in this chapter, according to agency rules and subject to the limitations and requirements in this chapter. See also WAC 182-531-0375 audiology services.

(2) The 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 182-500-0070;

(d) Authorized, as required within this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices;

(e) Billed according to this chapter, chapters 182-501 and 182-502 WAC, and the agency's published billing instructions and provider notices; ((and))

(f) The client ((is twenty years of age or younger and)) completes a hearing evaluation, including an audiogram ((and/or))or developmentally appropriate diagnostic physiologic test ((results performed and/or)), that is administered by and the results interpreted by a hearing health care professional; and

(g) The licensed audiologist, hearing aid specialist, otolaryngologist, or otologist concludes that the client may benefit from a hearing aid.

(((3) The agency requires prior authorization for covered hearing aids when the clinical criteria set forth in this chapter are not met. The agency evaluates these requests on a case-by-case basis to determine whether they are medically necessary, according to the process found in WAC 182-501-0165.))

The following definitions, the definitions found in RCW 18.35.010, and those found in chapter 182-500 WAC apply to this chapter.

"Digital hearing aids"(( - Hearing aids))means wearable sound-amplifying devices that use a digital circuit to analyze and process sound.

"Hearing aids"(( - ))means wearable sound-amplifying devices that are intended to compensate for hearing loss. These devices use a digital circuit to analyze and process sound. 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"(( - ))means an audiologist or hearing aid ((fitter/dispenser))specialist licensed under chapter 18.35 RCW, or ((an otorhinolaryngologist or otologist))a physician specializing in diseases and disorders of the ear licensed under chapter 18.71 RCW.

"Maximum allowable fee"(( - ))means the maximum dollar amount that the medicaid 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.))

(1) Clients ((twenty years of age and younger who are receiving services under a medical assistance program:

(c) Must be referred by a licensed audiologist, otorhinolaryngologist or otologist for a hearing aid))covered by one of the Washington apple health programs as listed in the table in WAC 182-501-0060 are eligible for hearing aids and related services.

(2) Clients ((who are)) enrolled in ((an))a medicaid 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))must arrange for hearing aid and related services directly through the client's MCO. Additionally, clients enrolled in an agency-contracted MCO must obtain replacement parts for cochlear implant((s))devices and bone-anchored hearing aids (((BAHA))), including batteries, through their MCO.

(1) The medicaid agency covers new, nonrefurbished, monaural or binaural hearing aid(s), which includes the ear molds, for eligible clients age 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 carry a manufacturer's warranty for a minimum of one year.

(2) The agency pays for the following replacements as long as the need for replacement is not due to the client's carelessness, negligence, recklessness, deliberate intent, or misuse in accordance with WAC 182-501-0050(((8))):

(a) Hearing aid(s), which includes the ear molds, 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 agency pays for repairs of hearing aids that are less than five years old 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 warranty is for a minimum of six months.

(b) A rental hearing aid(s) for up to thirty days while the client's own hearing aid is being repaired. In the case of a rental hearing aid(s), the agency pays separately for an ear mold(s).

(4) The agency pays for cochlear implant device and ((BAHA))bone-anchored hearing aid replacement parts when:

(a) The manufacturer's warranty has expired;

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

(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 ((182-502-0160))182-501-0050).

(5) The agency covers external sound processors for cochlear implant ((external speech processors))devices, including maintenance and repair.

(6) The agency covers ((BAHA))bone-anchored hearing aid speech processors, including maintenance and repair.

(7) The agency covers batteries for hearing aids, external sound processors for cochlear implant ((external speech processors))devices, and ((BAHA speech))bone-anchored hearing aid sound processors.

(1) Nonrefurbished, monaural hearing aids. The medicaid agency covers one new nonrefurbished monaural hearing aid, which includes the ear mold, every five years for clients age twenty-one and older.

(a) The client must have an average decibel loss of forty-five or greater in the better ear, based on a pure-tone audiometric evaluation by a licensed audiologist or a licensed hearing aid specialist at 1000, 2000, 3000, and 4000 hertz (Hz) with effective masking as indicated.

(b) The hearing aid must meet the client's specific hearing needs and carry a manufacturer's warranty for a minimum of one year.

(2) Binaural hearing aids. The agency covers binaural hearing aids. Prior authorization (PA) is required.

(3) Replacement. The agency covers the following replacements if the need for replacement is not due to the client's carelessness, negligence, recklessness, deliberate intent, or misuse under WAC 182-501-0050(7):

(a) One replacement hearing aid, including the ear mold, in a five-year period when the warranty is expired and the client's hearing aid(s) is:

(i) Lost; or

(ii) Broken and cannot be repaired.

(b) One replacement ear mold, per year, when the client's existing ear mold is damaged or no longer fits the client's ear.

(4) Repair of hearing aids. The agency covers two repairs, per hearing aid, per year, when the cost of 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:

(a) All warranties are expired; and

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

(5) Repair or replacement of external components of cochlear implant devices and bone-anchored hearing aids. The agency covers the following repair or replacement of external components of cochlear implant devices and bone-anchored hearing aids. PA is required.

(a) Repair or replacement of external components of cochlear implant devices. If the client has bilateral cochlear implant devices, both devices are eligible for repair and replacement of external components; and

(b) Repair or replacement of external components of bone-anchored hearing aids, whether implanted or worn with a headband. If the client has bilateral bone-anchored hearing aids, both devices are eligible for repair and replacement of external components.

(6) Rental of hearing aids. The agency covers rental hearing aid(s) for up to two months while the client's own hearing aid(s) is being repaired. For rental hearing aid(s) only, the agency pays separately for an ear mold(s).

(7) Second hearing aid. The agency pays for a second hearing aid when the client either meets the following clinical criteria or a limitation extension is requested and approved:

(a) The client tries one hearing aid for a ninety-day period, but the hearing aid does not adequately meet the client's hearing need; and

(b) One of the following reasons is documented in the client's record. The client is:

(i) Unable to or has difficulty with conducting job duties with only one hearing aid;

(ii) Unable to or has difficulty with functioning in the school environment with only one hearing aid;

(iii) Unable to live safely in the community with only one hearing aid; or

(iv) Legally blind.

(8) Batteries. The agency covers batteries for hearing aids, external sound processors for cochlear implant devices, and bone-anchored hearing aid sound processors.

(((1) The agency does not cover the following hearing and hearing aid-related items and services for clients twenty years of age and younger:

(2) When EPSDT applies, the agency evaluates a noncovered service, equipment, or supply according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 182-534-0100 for EPSDT rules).))(1) The medicaid agency does not cover the following items:

(1) Prior authorization is not required for clients age twenty ((years of age and under))and younger for hearing aid(s) and services.

(3) When billing, providers ((should))must send claims for clients age twenty ((years of age)) and younger directly to the medicaid agency. Providers do not have to obtain authorization from the local children with special health care needs (CSHCN) coordinator.

(((2) The 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 182-501-0169.))

(1) The agency requires prior authorization for covered hearing aids when the clinical criteria set forth in this chapter are not met. The agency evaluates these requests on a case-by-case basis to determine whether they are medically necessary, according to the process found in WAC 182-501-0165.

(2) For covered services that require prior authorization (PA), the provider must properly request authorization in accordance with the medicaid agency's rules and billing instructions.

(3) The agency evaluates requests for covered services that are subject to limitations or other restrictions and considers such services beyond those limitations or restrictions as described in WAC 182-501-0169.

(4) When the agency authorizes hearing aids or hearing aid-related services, the PA 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, providers must order and dispense hearing aids and hearing aid-related services within the authorized time frame.

(1) The medicaid agency's payment for purchased hearing aids includes all of the following:

(a) ((A prefitting))The audiometric evaluation;

(b) An impression for an ear mold;

(c) The ear mold; ((and

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

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

(3) The 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.