WSR 00-23-068

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed November 15, 2000, 3:22 p.m. ]

Date of Adoption: November 15, 2000.

Purpose: To clarify the language and hearing aid policy in compliance with the Governor's Executive Order 97-02.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-04001.

Statutory Authority for Adoption: RCW 74.08.090.

Adopted under notice filed as WSR 00-17-165 on August 22, 2000.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 5, Amended 0, Repealed 1.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 5, Amended 0, Repealed 1.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 5, Amended 0, Repealed 1. Effective Date of Rule: Thirty-one days after filing.

November 15, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

2821.5Chapter 388-544 WAC

VISION AND HEARING AID SERVICESHEARING AID SERVICES
NEW SECTION
WAC 388-544-1010
Definitions.

"Expedited prior authorization" (EPA) means a process designed by MAA to eliminate the need for written prior authorization (see definition for "prior authorization"). MAA establishes authorization criteria and identifies these criteria with specific codes. If the provider determines the client meets the criteria, the provider creates the authorization number using the specific MAA-established codes.

"FM systems" means a hearing device that uses a frequency modulated radio signal. FM systems are sometimes referred to as radio frequency (RF) aids.

"Limitation extension" (LE) means prior authorization from MAA to exceed the service limits (quantity, frequency, or duration) set in WAC or in MAA billing instructions.

"Maximum allowable fee" means the maximum dollar amount that MAA will reimburse a provider for specific services, supplies, and equipment.

"Prior authorization" means MAA and/or department of health approval for certain medical services, equipment, or supplies, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms of prior authorization.

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NEW SECTION
WAC 388-544-1100
Hearing aid services -- General.

(1) MAA covers only the hearing aid services listed in this chapter, subject to the exceptions, restrictions, and limitations listed in this chapter.

(2) MAA evaluates requests for services listed as noncovered or subject to limitations or restrictions according to the provisions in WAC 388-501-0165.

(3) MAA reimburses providers at the maximum allowable rates established by MAA.

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NEW SECTION
WAC 388-544-1200
Hearing aid services -- For adults.

This section applies to medical assistance clients eighteen years of age or older:

(1) MAA covers the purchase of one new, nonrefurbished hearing aid for an adult client every five years if all of the following conditions are met:

(a) The client must be:

(i) Eighteen years of age or older; and

(ii) Eligible for the categorically needy program or the medical care services program.

(b) The client must either:

(i) Have an average hearing of fifty decibel hearing level (dBHL) in the better ear based on auditory screening by a certified audiologist or licensed hearing instrument fitter/dispenser at one thousand, two thousand, three thousand, and four thousand Hertz (Hz) with effective masking as indicated; or

(ii) Be referred by a screening provider under the Healthy Kids/early and periodic screening, diagnosis, and treatment (EPSDT) program (only for clients eighteen to twenty years old).

(c) The client's current hearing aid, if the client has one, is not sufficient for the hearing loss in the better ear.

(d) The hearing aid must be:

(i) Medically necessary as defined in WAC 388-500-0005; and

(ii) Warranted for one year.

(2) Reimbursement for hearing aids includes:

(a) A prefitting evaluation;

(b) An ear mold; and

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

(3) MAA covers the repair of a hearing aid when the:

(a) Initial one-year warranty has expired;

(b) Client continues to meet the criteria in subsection (1) of this section;

(c) Cost of repair is less than fifty percent of the cost of a new hearing aid;

(d) Provider has documented the repair and replacement costs; and

(e) Repair is warranted for ninety days.

(4) MAA covers the cost of renting a hearing aid for up to two months while the client's own hearing aid is being repaired.

(5) MAA covers one replacement hearing aid in a five year period when the:

(a) Hearing aid is lost or broken beyond repair;

(b) Client continues to meet the criteria in subsection (1) of this section; and

(c) Provider has documented the necessity for the replacement.

(6) MAA covers replacement of ear molds as follows:

(a) Once a year for soft ear molds; and

(b) Once every three years for hard ear molds.

(7) Prior MAA authorization is required for the following services for adults:

(a) Bone conduction hearing aids; and

(b) Binaural hearing aids.

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NEW SECTION
WAC 388-544-1300
Hearing aid services -- For children.

This section applies to medical assistance clients seventeen years of age or younger:

(1) MAA covers the purchase of new, nonrefurbished hearing aids for children if all of the following conditions in subsections (1)(a) and (1)(b) are met:

(a) The child must:

(i) Be seventeen years of age or under;

(ii) Be eligible for any MAA medical program, except medically indigent program (MIP) and family planning only program; and

(iii) Have prior authorization from the child's local department of health's (DOH) children with special health care needs (CSHCN) coordinator to receive a hearing aid.

(b) The hearing aid must be:

(i) Medically necessary as defined in WAC 388-500-0005; and

(ii) Warranted for one year.

(2) Reimbursement for hearing aids includes:

(a) A prefitting evaluation;

(b) An ear mold for in-the-ear (ITE) hearing aids; and

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

(3) MAA covers the repair of a hearing aid when the:

(a) Client's local CSHCN coordinator authorizes the repair;

(b) Initial one-year warranty has expired;

(c) Client continues to meet the criteria in subsection (1) of this section;

(d) Cost of repair is less than fifty percent of the cost of a new hearing aid;

(e) Provider has documented the repair and replacement costs; and

(f) Repair is warranted for ninety days.

(4) MAA covers the cost of renting a hearing aid while the client's own hearing aid is being repaired when the rental is authorized for ninety days.

(5) MAA covers replacement of a hearing aid when the:

(a) Client's local CSHCN coordinator authorizes the replacement;

(b) Client continues to meet the criteria in subsection (1) of this section;

(c) Hearing aid is lost or broken beyond repair; and

(d) Provider has documented the necessity for the replacement.

(6) MAA covers replacement of hard and soft ear molds when the replacement is authorized by the client's local CSHCN coordinator.

(7) All hearing aid equipment and services for children require prior authorization from the client's local CSHCN coordinator, except FM systems which require prior authorization from MAA.

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NEW SECTION
WAC 388-544-1400
Hearing aid services -- Noncovered services.

(1) MAA does not cover any of the following:

(a) The purchase of batteries, ear trumpets, or tinnitus maskers;

(b) Group screenings for hearing loss, except as provided under the Healthy Kids/EPSDT program under WAC 388-534-0100;

(c) Computer-aided hearing devices used in school;

(d) Hearing aid charges reimbursed by insurance or other payer source;

(e) Digital hearing aids; or

(f) FM systems or programmable hearing aids for:

(i) Adults;

(ii) Children when the device is used in school; or

(iii) Children whose hearing loss is adequately improved with hearing aids.

(2) MAA evaluates a request for any service listed in this section according to the provisions of WAC 388-501-0165.

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REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 388-86-04001 Hearing aids.

Washington State Code Reviser's Office