907 KAR 1:038.
Hearing Program coverage provisions and requirements.
RELATES TO: KRS 205.520, 334.010(4), (9),
334A.020(5), 334A.030, 42 C.F.R. 441.30, 447.53, 457.310, 42 U.S.C. 1396a, b,
d, 1396r-6
STATUTORY AUTHORITY: KRS 194A.030(2),
194A.050(1), 205.520(3)
NECESSITY, FUNCTION, AND CONFORMITY: The
Cabinet for Health and Family Services, Department for Medicaid Services has responsibility
to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by
administrative regulation, to comply with any requirement that may be imposed
or opportunity presented by federal law to qualify for federal Medicaid funds.
This administrative regulation establishes the Medicaid Program provisions and
requirements regarding the coverage of audiology services and hearing
instruments.
Section 1. Definitions. (1)
"Audiologist" is defined by KRS 334A.020(5).
(2) "CPT code" means a code
used for reporting procedures and services performed by medical practitioners
and published annually by the American Medical Association in Current
Procedural Terminology.
(3) "Department" means the
Department for Medicaid Services or its designee.
(4) "Enrollee" means a
recipient who is enrolled with a managed care organization.
(5) "Federal financial participation"
is defined by 42 C.F.R. 400.203.
(6) "Healthcare Common Procedure
Coding System" or "HCPCS" means a collection of codes
acknowledged by the Centers for Medicare and Medicaid Services (CMS) that
represents procedures or items.
(7) "Hearing instrument" is
defined by KRS 334.010(4).
(8) "Managed care organization"
means an entity for which the Department for Medicaid Services has contracted
to serve as a managed care organization as defined in 42 C.F.R. 438.2.
(9) "Medically necessary" or
"medical necessity" means that a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.
(10) "Recipient" is defined by
KRS 205.8451(9).
(11) "Specialist in hearing
instruments" is defined by KRS 334.010(9).
Section 2. General Requirements. (1)(a)
For the department to reimburse for a service or item, the service or item
shall:
1. Be provided:
a. To a recipient under the age of
twenty-one (21) years, including the month in which the recipient becomes
twenty-one (21); and
b. By a provider who is:
(i) Enrolled in the Medicaid Program pursuant
to 907 KAR 1:672;
(ii) Except as provided by paragraph (b)
of this subsection, currently participating in the Medicaid Program pursuant to
907 KAR 1:671; and
(iii) Authorized to provide the service
in accordance with this administrative regulation;
2. Be covered in accordance with this administrative
regulation;
3. Be medically necessary; and
4. Have a CPT code or HCPCS code that is
listed on the Department for Medicaid Services Hearing Program Fee Schedule.
(b) In accordance with 907 KAR 17:015,
Section 3(3), a provider of a service to an enrollee shall not be required to
be currently participating in the fee-for-service Medicaid Program.
(2)(a) If a procedure is part of a
comprehensive service, the department shall:
1. Not reimburse separately for the procedure;
and
2. Reimburse one (1) payment representing
reimbursement for the entire comprehensive service.
(b) A provider shall not bill the
department multiple procedures or procedural codes if one (1) CPT code or HCPCS
code is available to appropriately identify the comprehensive service provided.
(3) A provider shall comply with:
(a) 907 KAR 1:671;
(b) 907 KAR 1:672; and
(c) All applicable state and federal
laws.
(4)(a) If a provider receives any duplicate
payment or overpayment from the department, regardless of reason, the provider
shall return the payment to the department.
(b) Failure to return a payment to the
department in accordance with paragraph (a) of this subsection may be:
1. Interpreted to be fraud or abuse; and
2. Prosecuted in accordance with applicable
federal or state law.
(c) Nonduplication of payments and
third-party liability shall be in accordance with 907 KAR 1:005.
(d) A provider shall comply with KRS
205.622.
(5)(a) An in-state audiologist shall:
1. Maintain a current, unrevoked, and
unsuspended license in accordance with KRS Chapter 334A;
2. Before initially enrolling in the
Kentucky Medicaid Program, submit proof of the license referenced in
subparagraph 1 of this paragraph to the department; and
3. Annually submit proof of the license
referenced in subparagraph 1 of this paragraph to the department.
(b) An out-of-state audiologist shall:
1. Maintain a current, unrevoked, and
unsuspended license to practice audiology in the state in which the audiologist
is licensed;
2. Before initially enrolling in the
Kentucky Medicaid Program, submit proof of the license referenced in
subparagraph 1 of this paragraph to the department;
3. Annually submit proof of the license
referenced in subparagraph 1 of this paragraph to the department;
4. Maintain a Certificate of Clinical
Competence issued to the audiologist by the American Speech-Language-Hearing
Association; and
5. Before enrolling in the Kentucky
Medicaid Program, submit proof of having a Certificate of Clinical Competence
issued to the audiologist by the American Speech-Language-Hearing Association.
(c) If an audiologist fails to comply
with paragraph (a) or (b) of this subsection, as applicable based on if the
audiologist is in-state or out-of-state, the:
1. Audiologist shall be ineligible to be
a Kentucky Medicaid Program provider; and
2. Department shall not reimburse for any
service or item provided by the audiologist effective with the date the
audiologist fails or failed to comply.
(6)(a) An in-state specialist in hearing
instruments shall:
1. Maintain a current, unrevoked, and
unsuspended license issued by the Kentucky Licensing Board for Specialists in
Hearing Instruments;
2. Before initially enrolling in the Kentucky
Medicaid Program, submit proof of the license referenced in subparagraph 1 of
this paragraph to the department;
3. Annually submit proof of the license
referenced in subparagraph 1 of this paragraph to the department;
4. Maintain a Certificate of Clinical
Competence issued to the specialist in hearing instruments by the American
Speech-Language-Hearing Association; and
5. Before enrolling in the Kentucky
Medicaid Program, submit proof of having a Certificate of Clinical Competence
issued to the specialist in hearing instruments by the American
Speech-Language-Hearing Association.
(b) An out-of-state specialist in hearing
instruments shall:
1. Maintain a current, unrevoked, and
unsuspended license issued by the licensing board with jurisdiction over specialists
in hearing instruments in the state in which the license is held;
2. Before initially enrolling in the
Kentucky Medicaid Program, submit proof of the license referenced in
subparagraph 1 of this paragraph to the department;
3. Annually submit proof of the license
referenced in subparagraph 1 of this paragraph to the department;
4. Maintain a Certificate of Clinical
Competence issued to the specialist in hearing instruments by the American
Speech-Language-Hearing Association; and
5. Before enrolling in the Kentucky
Medicaid Program, submit proof of having a Certificate of Clinical Competence
issued to the specialist in hearing instruments by the American
Speech-Language-Hearing Association.
(c) If a specialist in hearing
instruments fails to comply with paragraph (a) or (b) of this subsection, as
applicable based on if the specialist in hearing instruments is in-state or
out-of-state, the:
1. Specialist in hearing instruments
shall be ineligible to be a Kentucky Medicaid Program provider; and
2. Department shall not reimburse for any
service or item provided by the specialist in hearing instruments effective
with the date the specialist in hearing instruments fails or failed to comply.
Section 3. Audiology Services. (1)
Audiology service coverage shall be limited to one (1) complete hearing
evaluation per calendar year.
(2) Unless a recipient's health care
provider demonstrates, and the department agrees, that an additional hearing
instrument evaluation is medically necessary, a hearing instrument evaluation
shall:
(a) Include three (3) follow-up visits,
which shall be:
1. Within the six (6) month period
immediately following the fitting of a hearing instrument; and
2. Related to the proper fit and
adjustment of the hearing instrument; and
(b) Include one (1) additional follow-up
visit, which shall be:
1. At least six (6) months following the
fitting of the hearing instrument; and
2. Related to the proper fit and
adjustment of the hearing instrument.
(3)(a) A referral by a physician to an
audiologist shall be required for an audiology service.
(b) The department shall not cover an audiology
service if a referral from a physician to the audiologist was not made.
Section 4. Hearing Instrument Coverage.
Hearing instrument benefit coverage shall:
(1) If the benefit is a hearing
instrument model, be for a hearing instrument model that is:
(a) Recommended by an audiologist
licensed pursuant to KRS 334A.030; and
(b) Available through a
Medicaid-participating specialist in hearing instruments; and
(2) Except as provided by Section 5(3) of
this administrative regulation, not exceed $800 per ear every thirty-six (36)
months.[; and
(c) Be limited to the following procedures:
Code
Procedure
V5010
Assessment for Hearing instrument
V5011
Fitting, Orientation, Checking of Hearing instrument
V5014
Repair, Modification of Hearing Instrument
V5015
Hearing Instrument Repair Professional Fee
V5020
Conformity Evaluation
V5030
Hearing Instrument, Monaural, Body Aid Conduction
V5040
Hearing Instrument, Monaural, Body Worn, Bone
Conduction
V5050
Hearing Instrument, Monaural, In the Ear Hearing
V5060
Hearing Instrument, Monaural, Behind the Ear
Hearing
V5070
Glasses; Air Conduction
V5080
Glasses; Bone Conduction
V5090
Dispensing Fee, Unspecified Hearing Instrument
V5095
Semi-Implantable Middle Ear Hearing Prosthesis
V5100
Hearing Instrument, Bilateral, Body Worn
V5120
Binaural; Body
V5130
Binaural; In the Ear
V5140
Binaural; Behind the Ear
V5150
Binaural; Glasses
V5160
Dispensing Fee, Binaural
V5170
Hearing Instrument, Cros, In the Ear
V5180
Hearing Instrument, Cros, Behind the Ear
V5190
Hearing Instrument, Cros, Glasses
V5200
Dispensing Fee, Cros
V5210
Hearing Instrument, Bicros, In the Ear
V5220
Hearing Instrument, Bicros, Behind the Ear
V5230
Hearing Instrument, Bicros, Glasses
V5240
Dispensing Fee, Bicros
V5241
Dispensing Fee, Monaural Hearing Instrument,
Any Type
V5242
Hearing Instrument, Analog, Monaural, CIC (Completely
In the Ear Canal)
V5243
Hearing Instrument, Analog, Monaural, ITC (In
the Canal)
V5244
Hearing Instrument, Digitally Programmable
Analog, Monaural, CIC
V5245
Hearing Instrument, Digitally Programmable
Analog, Monaural, ITC
V5246
Hearing Instrument, Digitally Programmable
Analog, Monaural, ITE (In the Ear)
V5247
Hearing Instrument, Digitally Programmable
Analog, Monaural, BTE (Behind the Ear)
V5248
Hearing Instrument, Analog, Binaural, CIC
V5249
Hearing Instrument, Analog, Binaural, ITC
V5250
Hearing Instrument, Digitally Programmable
Analog, Binaural, CIC
V5251
Hearing Instrument, Digitally Programmable
Analog, Binaural, ITC
V5252
Hearing Instrument, Digitally Programmable,
Binaural, ITE
V5253
Hearing Instrument, Digitally Programmable,
Binaural, BTE
V5254
Hearing Instrument, Digital, Monaural, CIC
V5255
Hearing Instrument, Digital, Monaural, ITC
V5256
Hearing Instrument, Digital, Monaural, ITE
V5257
Hearing Instrument, Digital, Monaural, BTE
V5258
Hearing Instrument, Digital, Binaural, CIC
V5259
Hearing Instrument, Digital, Binaural, ITC
V5260
Hearing Instrument, Digital, Binaural, ITE
V5261
Hearing Instrument, Digital, Binaural, BTE
V5262
Hearing Instrument, Disposable, Any Type,
Monaural
V5263
Hearing Instrument, Disposable, Any Type, Binaural
V5264
Ear Mold (One (1) Ear Mold Per Year Per Ear
and if Medically Necessary)]
V5266
Hearing Instrument Battery (Limit of Four (4)
Per Instrument When Billed With A New Hearing Instrument Or A Replacement
Instrument)
V5267
Hearing Instrument Supplies, Accessories
V5299
Hearing Service Miscellaneous (May Be Used to
Bill Warranty Replacement Hearing Instruments But Shall be Covered Only if
Prior Authorized by the Department)]
Section 5. Replacement of a Hearing
Instrument. (1) The department shall reimburse for the replacement of a hearing
instrument if:
(a) A loss of the hearing instrument necessitates
replacement;
(b) Extensive damage has occurred necessitating
replacement; or
(c) A medical condition necessitates the
replacement of the previously prescribed hearing instrument in order to accommodate
a change in hearing loss.
(2) If replacement of a hearing
instrument is necessary within twelve (12) months of the original fitting, the
replacement hearing instrument shall be fitted upon the signed and dated
recommendation from an audiologist.
(3) If replacement of a hearing
instrument becomes necessary beyond twelve (12) months from the original
fitting:
(a) The recipient shall be examined by a
physician with a referral to an audiologist; and
(b) The recipient’s hearing loss shall be
re-evaluated by an audiologist.
Section 6. Noncovered services. The
department shall not reimburse for:
(1) A routine screening of an individual
or group of individuals for identification of a hearing problem;
(2) Hearing therapy except as covered
through the six (6) month adjustment counseling following the fitting of a
hearing instrument;
(3) Lip reading instructions except as
covered through the six (6) month adjustment counseling following the fitting
of a hearing instrument;
(4) A service for which the recipient has
no obligation to pay and for which no other person has a legal obligation to
provide or to make payment;
(5) A telephone call;
(6) A service associated with investigational
research; or
(7) A replacement of a hearing instrument
for the purpose of incorporating a recent improvement or innovation unless the
replacement results in appreciable improvement in the recipient’s hearing ability
as determined by an audiologist.
Section 7. Equipment. (1) Equipment used
in the performance of a test shall meet the current standards and
specifications established by the American National Standards Institute.
(2)(a) A provider shall ensure that any
audiometer used by the provider or provider’s staff shall:
1. Be checked at least once per year to
ensure proper functioning; and
2. Function properly.
(b) A provider shall:
1. Maintain proof of calibration and any
repair, if any repair occurs; and
2. Make the proof of calibration and
repair, if any repair occurs, available for departmental review upon the
department’s request.
Section 8. Federal Approval and Federal
Financial Participation. The department’s coverage of services pursuant to this
administrative regulation shall be contingent upon:
(1) Receipt of federal financial participation
for the coverage; and
(2) Centers for Medicare and Medicaid
Services’ approval for the coverage.
Section 9. Appeal Rights. An appeal of a
negative action regarding a Medicaid recipient who is:
(1) Enrolled with a managed care
organization shall be in accordance with 907 KAR 17:010; or
(2) Not enrolled with a managed care
organization shall be in accordance with 907 KAR 1:563.
Section 10. Incorporation by Reference.
(1) The "Department for Medicaid Services Hearing Program Fee Schedule",
December 2013, is incorporated by reference.
(2) This material may be inspected,
copied, or obtained, subject to applicable copyright law, at the Department for
Medicaid Services, Cabinet for Health and Family Services, 275 East Main
Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m. to 4:30 p.m.
or online at the department’s Web site at
http://www.chfs.ky.gov/dms/incorporated.htm. (Recodified from 904 KAR
1:038, 6-10-1986; Am. 18 Ky.R. 1625; eff. 1-10-1992; 20 Ky.R. 1714; eff. 2-2-1994;
23 Ky.R. 4009; 24 Ky.R. 119; eff. 6-18-1997; 25 Ky.R. 1254; 1660; eff. 1-19-1999;
28 Ky.R. 944; 1404; eff. 12-19-2001; 33 Ky.R. 594; 1377; 1560; eff. 1-5-2007;
34 Ky.R. 1820; 2110; eff. 4-4-2008; TAm 7-16-2013; 40 Ky.R. 1945; 2481; 2712; eff.
7-7-2014.)