HEALTH CARE AUTHORITY

(Medicaid Program)

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)) medicaid provider guides 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)) medicaid provider guides 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.

"Digital hearing aids" - Hearing aids that use a digital circuit to analyze and process sound.

"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.

(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.

(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.

(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).

(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.

(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.