907 KAR 1:038. Hearing Program coverage provisions and requirements[Hearing and Vision Program services]

Link to law: http://www.lrc.ky.gov/kar/907/001/038.htm
Published: 2015

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      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.)