SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)
Effective Date of Rule: January 1, 2011.
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%. 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.
Under RCW 34.05.350 the agency for good cause finds that immediate adoption, amendment, or repeal of a rule is necessary for the preservation of the public health, safety, or general welfare, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the public interest; that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule; and that in order to implement the requirements or reductions in appropriations enacted in any budget for fiscal years 2009, 2010, or 2011, which necessitates the need for the immediate adoption, amendment, or repeal of a rule, and that observing the time requirements of notice and opportunity to comment upon adoption of a permanent rule would be contrary to the fiscal needs or requirements of the agency.
Reasons for this Finding: 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%. 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. Delaying the adoption of these cuts to optional services could jeopardize the state's ability to maintain the mandatory medicaid services for the majority of DSHS clients.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.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: December 23, 2010.
Katherine I. Vasquez
(1) The department covers the hearing aids ((
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 ((
. 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
(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
(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.]
(a) Are eligible for covered hearing aids ((
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.]
(2) The department pays for:
(a) Replacement hearing aid(s), which includes the ear mold, when:
(i) The client's hearing aid(s) are:
(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 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) 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).
(3) 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.
(4) The department covers for one cochlear implant external speech processor, including maintenance and repair.
(5) 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.]
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.|