WSR 09-12-034

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Health and Recovery Services Administration)

[ Filed May 27, 2009, 10:26 a.m. , effective July 1, 2009 ]


Effective Date of Rule: July 1, 2009.

Purpose: The purpose of these rule changes is to bring the hearing aids and services program in line with current industry standards as much as possible, reorganize the hearing aids and services WACs into their own chapter, and separate out the policy by adults and children. The major changes to the rules include removal of the cumbersome and costly prior authorization (PA) process for children as requested by its hearing aid providers, thus allowing quicker access to hearing aids and services for children, and removal of PA requirements for bone conduction hearing aids for adults. The department lowered the average degree of hearing loss decibel requirement which expands the availability of hearing aids to a larger population and removed digital and programmable hearing aids from the noncovered list. In addition, the department added pocket talkers and similar devices to the noncovered list for adults and changed the criteria for replacement ear molds for adults to once a year regardless of whether they are soft or hard.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-544-1010, 388-544-1100, 388-544-1200, 388-544-1300, and 388-544-1400.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.530.

Adopted under notice filed as WSR 09-04-091 on February 4, 2009.

A final cost-benefit analysis is available by contacting Jean Gowen, DSHS/HRSA, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-2005, fax (360) 586-9727, e-mail gowenje@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 11, Amended 0, Repealed 5.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 11, Amended 0, Repealed 5.

Date Adopted: May 19, 2009.

Susan N. Dreyfus

Secretary

4063.5
Chapter 388-547 WAC

HEARING AIDS


NEW SECTION
WAC 388-547-0100   Hearing aids--General.   Unless otherwise defined in WAC 388-547-0200, the terms within this chapter are intended to correspond with the terms in chapter 18.35 RCW.

(1) The department covers the hearing aid services listed in this chapter, according to department rules and subject to the limitations and requirements in this chapter.

(2) The department pays for hearing aids and services when:

(a) Covered. 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 younger;

(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;

(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) Completes a hearing evaluation, including an audiogram and/or developmentally appropriate diagnostic physiologic test results performed and/or interpreted by a hearing healthcare professional;

(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 aid 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.

[]


NEW SECTION
WAC 388-547-0200   Hearing aids--Definitions.   "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 healthcare 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 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.

[]


NEW SECTION
WAC 388-547-0300   Hearing aids--Eligibility--Clients twenty-one years of age and older.   (1) Hearing aid services are available to clients twenty one years of age or older covered under:

(a) A categorically needy (CN) medicaid program; or

(b) General assistance (GAU/ADATSA) (within Washington state and designated border cities.

(2) Clients who are enrolled in a department-contracted managed care plan 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.

[]


NEW SECTION
WAC 388-547-0400   Hearing aids--Covered services--Clients twenty-one years of age and older.   The department covers all of the following for eligible clients twenty-one years of age and older, without prior authorization:

(1) One new, nonrefurbished, monaural hearing aid, which includes the ear mold, every five years when the hearing aid meets the client's specific hearing needs and is under warranty for a minimum of one year.

(2) One replacement hearing aid, which includes the ear mold, in a five year period when the client's hearing aid(s) is lost or beyond repair and all warranties are expired.

(3) A replacement ear mold once a year when the client's existing ear mold is damaged or no longer fits the client's ear.

(4) 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:

(a) All warranties are expired; and

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

(5) 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).

[]


NEW SECTION
WAC 388-547-0500   Hearing aids--Noncovered services--Clients twenty-one years of age and older.   The department does not cover the following hearing and hearing aid-related items for eligible clients twenty-one years of age and older:

(1) Batteries;

(2) Tinnitus maskers;

(3) FM systems; or

(4) Pocket talkers or similar devices.

[]


NEW SECTION
WAC 388-547-0600   Hearing aids--Prior authorization--Clients twenty-one years of age and older.   (1) The department requires prior authorization for binaural hearing aids for eligible clients twenty-one years of age and older.

(2) The department 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.

(3) To request prior authorization from the department, a provider must fax the prior authorization request to the department using the appropriate fax number listed in published hearing aid services billing instructions.

(4) When the department authorizes hearing aids and/or services, the prior authorization 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, hearing aids and/or services must be ordered and dispensed within the authorized timeframe.

[]


NEW SECTION
WAC 388-547-0700   Hearing aids--Eligibility--Clients twenty years of age and younger.   (1) Clients twenty years of age and younger who are receiving services under any medical assistance program, except for the family planning only program and the TAKE CHARGE program:

(a) Are eligible for covered hearing aids and services under this chapter and for the audiology services under WAC 388-545-0700;

(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 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.

[]


NEW SECTION
WAC 388-547-0800   Hearing aids--Covered services--Clients twenty years of age and younger.   (1) The department 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 pays for:

(a) Replacement 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) 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).

[]


NEW SECTION
WAC 388-547-0900   Hearing aids--Noncovered services--Clients twenty years of age and younger.   (1) The department 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; or

(c) Computer-aided hearing devices for FM systems used in school.

(2) When EPSDT applies, the department evaluates a noncovered service, equipment, or supply according to the process in WAC 388-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC 388-534-0100 for EPSDT rules).

[]


NEW SECTION
WAC 388-547-1000   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. Providers do not have to obtain authorization from the local children with special health care needs (CSHCN) coordinator.

(2) The department 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.

[]


NEW SECTION
WAC 388-547-1100   Hearing aids--Reimbursement--General.   (1) The department'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 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 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.

[]


REPEALER

     The following sections of the Washington Administrative Code are repealed:
WAC 388-544-1010 Definitions.
WAC 388-544-1100 Hearing aid services -- General.
WAC 388-544-1200 Hearing aid services -- For adults.
WAC 388-544-1300 Hearing aid services -- For children.
WAC 388-544-1400 Hearing aid services -- Noncovered services.

Washington State Code Reviser's Office