5101:3-10-11 Hearing aids.

(A) Definitions.

(1) “Audiologist.”

A person licensed to practice audiology in Ohio under Chapter 4753. of the Revised Code, or who is licensed and practicing in another state and is employed by an eligible Ohio medicaid provider. This individual is authorized to provide hearing screening consistent with the provisions detailed in rule 4753-6-01 of the Administrative Code and audiologic evaluation consistent with the provisions detailed in division (G) of section 4753.01 of the Revised Code.

(2) “Licensed hearing aid dealer/fitter.”

A person licensed in Ohio under Chapter 4747. of the Revised Code, or who is licensed and practicing in another state and is an eligible Ohio medicaid provider. This individual is authorized to provide hearing screening and testing consistent with the provisions detailed in rules 4747-01-02 and 4747-01-19 of the Administrative Code.

(3) “Programmable.”

A hearing aid that utilizes analog technology that is controlled by modifying the frequency and output characteristics using a computer. It may contain multiple microphones, multiple memories and multiple channels, and may operate with a remote control.

(4) “Digital.”

A digital hearing aid analyzes incoming sound, transforms it by converting the sound into digital bits and manipulates the frequency and output characteristics of the sound before the sound is amplified. Digital hearing aids are programmed with a computer and contain multiple memories, microphones, and channels. The digital processor permits the hearing aid to change its parameters, to reduce background noise, and/or eliminate feedback without adversely affecting the benefits for the user.

(5) “Conventional.”

Conventional hearing aids have a microphone that gathers sound, an amplifier that increases the volume of sound, and a receiver that transmits this amplified sound to the ear. These instruments have a manual volume control for the user. These devices have screw-set controls mounted onto the hearing aids for the hearing health care professional to adjust.

(B) Hearing aids of any type must be prior authorized before being eligible for reimbursement by Ohio medicaid. The prior authorization (PA) request must include all of the following documentation:

(1) A fully completed, most current version of prior authorization (PA) form (JFS 03142, rev. 02/2003);

(2) A description, including approximate age and ownership, of any similar equipment in possession of the consumer and the reason for the new request if similar equipment ownership is established; and

(3) A current physician’s prescription that verifies the need for a hearing aid by certifying that the provided hearing test results, when interpreted as a set, clearly demonstrate hearing loss and includes a written statement verifying that the performance of a medical examination has indicated that the hearing loss is not due to a temporary, correctable physical condition; e.g., ear infection or impacted wax. The physician’s prescription cannot be dated more than six months prior to the date of the PA request. For the purposes of medicaid reimbursement, the exception allowing the opportunity to waive the medical evaluation for a medical referral or medical evaluation for a consumer eighteen years of age or older specified in paragraph (A)(10) of rule 4747-1-19 of the Administrative Code or paragraph (C)(2) of rule 4753-8-03 of the Administrative Code cannot be applied to medicaid consumers;

(4) Documentation of a hearing evaluation that supports the consumer’s need for a hearing aid and includes all of the following components:

(a) A hearing test that was performed and signed by a physician specializing in otology or otolaryngology, an audiologist, or a hearing aid fitter;

(b) The hearing test report which reflects the specific hearing values resulting from the test; and

(c) A written summation of the hearing test results, performed and signed by a physician specializing in otology or otolaryngology, or an audiologist. The individual performing either the hearing test, the written summation of the hearing test results, or both, must provide a legible name and provider type with his or her documentation (i.e., physician, audiologist or hearing aid fitter). This information must accompany the provider signature. The hearing evaluation must not have been performed more than six months prior to the date of the PA request; and

(5) Documentation from the physician who is authorizing a digital/programmable hearing aid for a consumer twenty years of age or younger that states the digital/ programmable hearing aid will offer superior performance over a conventional hearing aid for the specific consumer in question. This documentation should also include statements attesting that the particular consumer requires functions that are not found in a conventional hearing aid (i.e., automatic feedback reduction, automatic noise reduction, programmable volume control) and that the digital/programmable hearing aid is necessary for the consumer’s success in educational development; and

(6) Dispensing fee codes as referenced in paragraph (M) of this rule and hearing aid codes must be submitted together on the same prior authorization (PA) request and if approved must be billed together with the same date of service.

(1) Hearing tests for consumers twenty-one years or older shall include, at a minimum, all of the following for a basic hearing test:

(a) At least four thresholds for air conducted stimuli of five hundred Hz, one thousand Hz, two thousand Hz, and four thousand Hz;

(b) Air conducted speech awareness, or speech reception threshold;

(d) Bone-conducted pure-tone evaluation, unless the consumer’s cognitive abilities do not permit such testing. Hearing test results shall be obtained bilaterally unless the recipient’s behavior/condition does not permit bilateral evaluation. If bilateral testing cannot be done, supporting documentation regarding this issue must be provided. All tests shall be performed in an appropriate sound environment in accordance with the standards accepted by the American national standards institute (ANSI S3.1-1999, R2003).

(2) Evaluation of results for consumers twenty-one years or older must show a best pure-tone average of thirty-one dB HL or greater and in conjunction with the remainder of the hearing evaluation, results that demonstrate the need for a hearing aid. If physical or developmental limitations preclude these evaluation results an explanation and alternative evaluation results must be provided.

(3) Hearing tests for consumers age twenty years or younger shall include, at a minimum, all of the following for a basic hearing test:

(a) At least four thresholds for air conducted stimuli of five hundred Hz, one thousand Hz, two thousand Hz, and four thousand Hz;

(b) Air conducted speech awareness, or speech reception threshold;

(d) Bone-conducted pure-tone evaluation, unless the consumer’s cognitive abilities do not permit such testing;

(e) Tympanometry;

(f) Acoustic reflex battery; and

(g) Otoacoustic emissions testing.

Hearing test results shall be obtained bilaterally unless the recipient’s behavior/condition does not permit bilateral testing. If bilateral testing cannot be done, supporting documentation regarding this issue must be provided. All tests shall be performed in an appropriate sound environment in accordance with the standards accepted by the (ANSI S3.1-1999, R2003).

(4) Hearing test results for consumers aged twenty years or younger must show a best pure-tone average of twenty six dB HL or greater and when interpreted in conjunction with the remainder of the hearing test results that constitute a basic hearing test must demonstrate the need for a hearing aid. If physical or developmental limitations preclude these evaluation results, an explanation and alternative evaluation results must be provided. Hearing test results for consumers aged twenty years or younger are valid for prior authorization purposes only if the testing was conducted by a provider authorized to perform the complete battery of hearing tests that are listed in paragraph (C)(3) of this rule as part of their respective scope of practice.

(D) The following types of hearing aids are not covered by Ohio medicaid:

(1) All types of “in the canal” and “completely in the canal” hearing aids;

(2) All types of disposable hearing aids;

(3) “Used” or reconditioned hearing aids, which are defined as hearing aids that have been previously utilized by another individual; and

(4) Digital and programmable hearing aids for adults twenty-one years or older.

(E) Conventional hearing aids.

(1) Adults twenty one years or older are eligible for conventional hearing aids only.

(2) Hearing evaluation results referenced in paragraph (C)(1) of this rule must clearly demonstrate the need for a hearing aid.

(3) All conventional hearing aids dispensed must be covered by a one-year warranty to include coverage provisions for all parts (except earmolds and batteries), comprehensive loss, damage, and labor.

(4) Providers must maintain copies of the manufacturer’s cost estimate and the final manufacturer’s invoice, including discounts and shipping costs, in the consumer’s record and make them available to the Ohio department of job and family services (ODJFS) upon request.

(5) All provisions of this rule apply to conventional hearing aids with the exception of paragraph (F) of this rule.

(6) Payment for a conventional hearing aid is the lesser of the medicaid maximum listed in rule 5101:3-1-60 of the Administrative code for a conventional aid or the provider’s acquisition cost, which consists of the manufacturer’s invoice price minus any discounts received by the vendor plus shipping costs.

(7) If the manufacturer’s final invoice price does not match the cost estimate submitted as part of the prior authorization request for the conventional hearing aid for any reason, the provider must submit a new prior authorization request reflecting the changed price in order to be eligible for reimbursement.

(8) Providers must maintain copies of the manufacturer’s cost estimate and the final manufacturer’s invoice including discounts and shipping costs in the patient’s record and make them available to ODJFS upon request.

(F) Programmable and digital hearing aids.

(1) Programmable and digital hearing aids are only eligible for reimbursement if the consumer is twenty years of age or younger and a programmable and digital hearing aid is medically necessary as defined in paragraph (B) of this rule .

(2) Hearing evaluation results referenced in paragraph (C)(4) of this rule must clearly demonstrate the need for a hearing aid.

(3) All programmable and digital hearing aids dispensed must be covered by a twoyear warranty to include coverage provisions of all parts (except earmolds and batteries), comprehensive loss, damage, and labor.

(4) Payment for a digital or programmable hearing aid is the lesser of the medicaid maximum listed in rule 5101:3-1-60 of the Administrative code for a programmable or digital aid or the provider’s acquisition cost, which consists of the manufacturer’s invoice price minus any discounts received by the vendor plus shipping costs.

(5) If the manufacturer’s final invoice price does not match the programmable or digital hearing aid cost estimate submitted as part of the prior authorization request due to any reason, the provider must submit a new prior authorization request reflecting the changed price in order to be eligible for reimbursement.

(6) Providers must maintain copies of the manufacturer’s cost estimate and the final manufacturer’s invoice including discounts and shipping costs in the patient’s record and make them available to ODJFS upon request.

(7) Payment for a programmable or digital hearing aid includes two adjustments per year for the duration of the first-year warranty for comprehensive loss, damage and repair, and two adjustments per year under a second-year warranty for comprehensive loss, damage and repair. If adjustment is necessary due to documented changes in measured hearing sensitivity or the growth of the ear canal, payment for adjustment will be authorized as a repair if this is the third adjustment during a warranty period for comprehensive loss, damage, and repair. In addition, the repair provisions stated in rule 5101:3-10-08 of the Administrative Code must be met.

(G) Binaural hearing aids, “CROS,” and “BiCROS” aids are not routinely covered by the medicaid program but may be authorized for persons with special documented needs; e.g., child for whom binaural hearing is necessary for development of speech. This documentation must be submitted at the time of the original PA request in order to be considered for coverage.

(H) Hearing aids may be dispensed by a physician, a licensed audiologist, or a licensed hearing aid fitter who is enrolled as a durable medical equipment (DME) provider or enrolled as a physician or clinic type provider who has also been assigned a DME category of service.

(I) All earmolds must be warranted for ninety days. After the warranty period, necessary earmolds or repairs that are within the maximum allowances specified in rule 5101:3-10-20 of the Administrative Code will not require prior authorization. Prior authorization requests for earmolds in excess of the maximum allowed will be considered for special cases when appropriate documentation of medical necessity is provided. Visits to a hospital, home, nursing facility (NF), or intermediate care facility for the mentally retarded (ICF-MR) for the purpose of taking an earmold impression are covered but subject to limitations specified in rule 5101:3-10-20 of the Administrative Code.

(J) Each consumer of a hearing aid shall be scheduled for a recheck to assess the performance and consumer acceptability of the aid within thirty days of receipt of the aid by the consumer. A copy of the recheck report, countersigned by the consumer or an explanation of why the recheck was not performed, shall be maintained in the provider’s file for a period of four years. No claim for payment should be made prior to a recheck or thirty days from the initial fitting of the aid, whichever comes first.

(K) When a recheck is performed within thirty days and the hearing aid is deemed unacceptable by both the hearing aid provider and the consumer, the cost of the earmold, batteries, and one month’s use of the instrument will be borne by the ODJFS. On the rare occasions that this may happen, the original authorization form must be forwarded to ODJFS for cancellation and subsequent issuance of a revised authorization reflecting the new cost. If payment has been made on the original authorization, no adjustment to payment will be authorized.

(L) Payment for all types of hearing aids includes all of the following:

(1) Hearing aid, cleaning kit, earmold insert when required for behind the ear style hearing aids, and a one-month supply of batteries;

(2) Shipping and handling;

(3) All required warranty costs; and

(4) Hearing tests as specified in sections (C)(1) and (C)(3) of this rule. Only providers specified in paragraph (B)(4) of this rule may bill ODJFS for hearing tests in conjunction with the fitting and dispensing of any type of hearing aid.

(M) Effective for dates of service on and after the effective date of this rule, ODJFS will pay a separate fee for dispensing a hearing aid. These fees can be located in 5101:3-1-60 of the Administrative code. ODJFS will reimburse only one dispensing fee code per consumer every four years for a conventional hearing aid or once every five years for a programmable or digital hearing aid.

(N) Payment for any hearing aid dispensing fee includes all of the following:

(1) Earmold impression(s);

(2) Hearing aid selection and fitting(s);

(3) Up to three hours of counseling;

(4) All visits necessary for the dispensing and fitting of the aid (regardless of place of service); and

(5) All service calls and follow-up during the warranty period.

(O) In general, reimbursement for a hearing aid will be limited to a maximum of one aid in any four-year period for a conventional hearing aid. Reimbursement for a digital or programmable hearing aid will be limited to a maximum of one hearing aid in any five year period. Requests for more frequent replacement for medically necessary reasons will be considered when appropriate documentation is provided. A request for replacement of a hearing aid for non-medical reasons will be considered. However, cases suggesting malicious damage, neglect, culpable irresponsibility, or wrongful disposition of the hearing aid will be investigated and denied where ODJFS determines it is unreasonable to make program payment under the circumstances. If a hearing aid is lost and is still covered by warranty, ODJFS will not cover any deductible or replacement charges not covered by warranty.

(P) A copy of the manufacturer’s warranty and any applicable insurance coverage shall be maintained in the provider’s file for a period of five years and copies shall be provided to ODJFS on request.

(Q) No hearing aid will be authorized for replacement until ODJFS has received proof that replacement is not covered by the manufacturer’s warranty or insurance. A request for prior authorization of a replacement hearing aid outside of the warranty period must meet all the requirements of this rule. No hearing aid will be authorized for replacement if repair or reconditioning would be more cost-effective.

(R) A provider may bill ODJFS for necessary repair of a hearing aid only if the following conditions exist:

(1) The aid had been acquired through ODJFS; or

(2) ODJFS has determined that the aid, not acquired through the program, is medically necessary; and

(3) The repair is not covered by warranty or insurance; and

(4) All of the requirements for repairs listed in rule 5101:3-10-08 of the Administrative Code are met.

(S) ODJFS will pay for only one hearing aid code and only one unit per consumer per date of service in a four-year period as discussed in paragraph (O) of this rule for a conventional hearing aid or only one hearing aid code and only one unit per consumer per date of service in a five-year period for a programmable or digital hearing aid.

Replaces: 5101: 3-10-11

Effective: 09/01/2005

R.C. 119.032 review dates: 09/01/2010

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02

Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/1/80, 3/1/84, 5/1/90, 2/1/93, 12/10/93, 1/1/95