Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 45 - Hearing Aid Program › Section 13 CSR 70-45.010 - Hearing Aid Program

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment clarifies participants that
				  are eligible to receive hearing aid services and removes criteria that are no
				  longer applicable or are outdated.
(1) Administration. The Hearing Aid Program
				shall be administered by the Department of Social Services, MO HealthNet
				Division. The services and items covered and not covered, the program
				limitations, and the maximum allowable fees for all covered services shall be
				determined by the Department of Social Services, MO HealthNet Division through
				the hearing aid manual which is incorporated by reference and made a part of
				this rule, as published by the Department of Social Services, MO HealthNet
				Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at
				dss.mo.gov/mhd, May 13, 2020. This rule does not incorporate any subsequent
				amendments or additions.
(2)
				Participants Eligible. The MO HealthNet Program pays for approved MO HealthNet
				services for hearing aid services when furnished within the provider's scope of
				practice to MO HealthNet eligible participants under the age of 21 or
				participants receiving MO HealthNet under a category of assistance for pregnant
				women, blind participants, or skilled nursing facility residents. The
				participant must be eligible on the date the service is furnished. Participants
				may have specific limitations for hearing aid services according to the type of
				assistance for which they have been determined eligible. It is the provider's
				responsibility to determine the coverage benefits for a participant based on
				their type of assistance as outlined in the provider program manual. The
				provider shall ascertain the patient's MO HealthNet and managed care or other
				lock-in status before any service is performed. The participant's eligibility
				shall be verified in accordance with methodology outlined in the hearing aid
				manual.
(3) Prior Authorization of
				Hearing Aids. All hearing aids and related services require prior authorization
				with the exception of hearing evaluation for the purpose of prescribing a
				hearing aid, post-fitting evaluations, post-fitting adjustments, repairs to
				hearing aids no longer under warranty, and special tests for ruling out
				retro-cochlear involvement. All hearing aid program services provided to
				participants in nursing facilities require prior authorization.
(4) Hearing Evaluation Requirements. A
				hearing evaluation for the purpose of obtaining a hearing aid must be performed
				by an audiologist, hearing instrument specialist, or physician (MD or DO) prior
				to the submission of a Prior Authorization Request form. This testing, when
				administered for the purpose of prescribing a hearing aid, will be reimbursed
				by the MO HealthNet program. Testing performed in relation to a medical or
				surgical diagnosis or treatment for hearing deficits or related medical
				problems for purposes other than determining the need for a hearing aid is a
				noncovered service and is not reimbursable by the MO HealthNet Hearing Aid
				Program. The hearing evaluation performed for the purpose of obtaining a
				hearing aid must include, at a minimum, air conduction thresholds, bone
				conduction thresholds (with masking when necessary), speech reception
				thresholds and speech discrimination scores. The results obtained from these
				basic hearing tests must be clear and internally consistent, and must
				demonstrate that a hearing aid is needed, that it will benefit the participant
				and will support the recommendation of which ear is to be fitted. Testing must
				be provided in accordance with sound professional practice and the standards
				under which the provider is licensed.
(5) Hearing Loss (HL) Requirement. A
				participant's pure-tone average (PTA) must be thirty decibels (30dB) HL or
				greater in the better ear to qualify for a hearing aid. The PTA is the average
				air-conduction threshold for five hundred (500), one thousand (1,000), and two
				thousand (2,000) Hertz (Hz) measured with an earphone. Word recognition must be
				tested with a minimum of twenty-five (25) phonetically balanced word lists.
(6) Medical Ear Examination
				Requirements. The participant must receive a medical ear examination for
				pathology or disease by a physician licensed as an MD or DO. The medical ear
				examination must be performed within six (6) months prior to the date a hearing
				aid is dispensed.
(7) Obtaining and
				Fitting the Aid. Only after receipt of an approved Prior Authorization Request
				form should the provider proceed with the fitting and dispensing of the hearing
				aid.
(8) Post-fitting Evaluation. A
				post-fitting evaluation will be performed no sooner than fourteen (14) days or
				later than thirty (30) days after the hearing aid is dispensed. If the hearing
				aid is not providing adequate and substantial correction of the loss,
				reimbursement will not be made for the hearing aid.
(9) Reimbursement for Hearing Aids and
				Related Services. Payment will be made for each unit of service or item
				provided in accordance with the fee schedule determined by the MO HealthNet
				Division. Providers must bill their costs for the hearing aids. Reimbursement
				will not exceed the lesser of the maximum allowed amount determined by the MO
				HealthNet Division or the provider's billed charge.
(10) Services/Items Provided in a Nursing
				Home. A request for hearing evaluation for the purpose of prescribing a hearing
				aid must originate with the participant and must proceed with the participant's
				full knowledge and consent. All hearing aids and related services performed or
				provided in a nursing home, boarding home, domiciliary home, or institution
				require prior authorization as specified in section (3), with the exception
				that hearing evaluation for the purpose of prescribing a hearing aid being
				performed in these places of service also requires prior
				authorization.
(11) Binaural
				Hearing Aids. Binaural hearing aids may be covered by MO HealthNet if medically
				necessary and if prescribed by an otolaryngologist, otologist, or
				otorhinolaryngologist.
(12)
				Replacement Hearing Aids. Prior authorization may be granted for a second
				hearing aid within four (4) years if the first hearing aid was lost, destroyed,
				or ceased to function effectively and cannot be repaired.
(13) Hearing Aid Repairs. MO HealthNet covers
				necessary repairs to any eligible participant's hearing aid that is no longer
				under warranty. The warranty period on new hearing aids or repairs will be for
				one (1) year from the date the hearing aid is dispensed. The methods of
				reimbursement for repairs are as follows:
(A)
				Out-of-shop Repairs. Necessary repairs made out-of-shop, where the hearing aid
				must be sent out to the manufacturer or repair lab, will be reimbursed at
				twenty dollars ($20) plus the invoiced cost of the repair. The twenty dollars
				($20) covers the provider's cost for postage and processing. Included also is
				any postage for returning the hearing aid to the provider, any insurance fee
				charged and a six- (6-) month warranty; and
(B) In-shop Repairs. Necessary repairs made
				in-shop will be reimbursed at the provider's cost for parts plus a reasonable
				charge for labor. The state consultant will determine the reasonable charge for
				labor. Repairs will be considered as in-shop repairs for-
1. Any repair made in the provider's
				office;
2. Any repair made in a
				provider-owned and/or operated repair or manufacturing lab; or
3. Any repair made by a provider who is
				employed by or affiliated with another provider who owns or operates a repair
				or manufacturing lab.