Ohio Admin. Code 5160-10-11 - DMEPOS: hearing aids

(A) Definition. "Basic hearing test" is an evaluation of an individual's ability to hear that includes the following components:

(1) Testing of air-conducted stimuli at thresholds of five hundred hertz (Hz), one thousand Hz, two thousand Hz, and four thousand Hz;

(2) Assessment of air-conducted speech awareness or speech reception threshold;

(3) Establishment of most comfortable and most uncomfortable listening levels;

(4) Pure-tone bone conduction audiometry (unless the individual's age or capability precludes such testing); and

(5) For an individual younger than twenty-one years of age, the following components:

(a) Tympanometry;

(b) Acoustic reflex battery; and

(c) Otoacoustic emissions testing.

(B) Coverage.

(1) The default certificate of medical necessity (CMN) form is the ODM 01915, "Certificate of Medical Necessity: Hearing Aids" (rev. 7/2018).

(2) A completed CMN, signed and dated not more than ninety days before the requested dispensing date, must be is accompanied by a hearing evaluation report, compiled not more than six months before the requested dispensing date, made up of the following components:

(a) A detailed description of the hearing test, signed by the physician specializing in otology or otolaryngology, audiologist, or licensed hearing aid fitter who administered it;

(b) A copy of the hearing test results; and

(c) A written summation of the hearing test results, prepared and signed by a physician specializing in otology or otolaryngology or by an audiologist.

(3) Separate payment may be made for the hearing test itself,. All hearing tests must be administered by authorized individuals working within their scope of practice and must be conducted in an appropriate sound environment in accordance with nationally accepted standards. Hearing tests should be performed on both ears; a detailed explanation must be included in a PA request is needed if bilateral testing cannot be done.

(4) The need for a hearing aid is demonstrated when the results of a basic hearing test performed on one ear indicate the following minimum best pure-tone average hearing loss:

(a) Thirty-one decibels (dB); or

(b) In an individual younger than twenty-one years of age, twenty-six dB.

(5) To assess the performance and acceptability of the hearing aid, the provider must attempt to schedule a follow-up visit with the individual within thirty days after delivery. No claim for payment should be submitted during this period. The provider must keep on file, for at least four years, either a confirmation of the follow-up visit signed by the individual or an explanation of why the visit was not conducted. If as a result of the follow-up visit the hearing aid is deemed unacceptable by either the provider or the individual, then payment is limited to the cost of the earmold insert and batteries. In such an instance, if payment has already been made for the hearing aid, then the provider must arrange for adjustment of the claim. A claim for payment should be submitted only after the acceptability of the hearing aid has been confirmed, usually during a follow-up visit scheduled within thirty days after delivery. The individual may instead confirm acceptability by waiving the follow-up visit. In either case, the provider maintains relevant documentation. If the hearing aid is deemed unacceptable by either the provider or the individual, then payment is limited to the cost of the earmold insert and batteries. If payment has already been made for the hearing aid, then the claim is to be adjusted.

(6) The following warranty periods apply:

(a) For a covered hearing aid, it is the greater of the manufacturer's warranty period or one year from the date of delivery; and

(b) For an earmold insert, it is ninety days.

(7) A warranty comprehensively covers the following services:

(a) Repair, including labor and parts (except earmold inserts and batteries);

(b) Replacement necessitated by damage or loss; and

(c) Two adjustments per year for changes in hearing sensitivity or growth of the ear canal (after which additional adjustments made during the year will be treated as repairs).

(8) A programmable hearing aid, such as a hearing aid employing contralateral routing of signal (CROS) or binaural contralateral routing of signal (BiCROS), may be indicated if an individual has a documented need for such technology in noisy or otherwise adverse hearing environments.

(9) Separate payment may be made for the taking of an impression for an earmold insert (other than an insert dispensed with a hearing aid). Such payment is limited neither by the place of service nor by the individual's living arrangement.

(10) Regardless of how a hearing aid was purchased, payment may be made for necessary repair only if the following conditions are satisfied:

(a) The medical necessity of the hearing aid has been established;

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

(c) The repair is not associated with routine maintenance or cleaning of the hearing aid.

(C) Requirements, constraints, Constraints and limitations.

(1) The provider must keep on file department may at any time ask a provider to produce a copy of the manufacturer's original cost estimate, a copy of the manufacturer's final invoice detailing discounts and shipping costs, and (if applicable) an explanation of any differences between the figures.

(2) No payment will be made for the following hearing aids:

(a) A hearing aid designed to be worn inside the ear canal;

(b)(a) A disposable hearing aid; and

(c)(b) A hearing aid that has been previously used by another individual.

(3) No payment (including payment of a deductible amount) will be made for replacement if either of the following conditions is satisfied:

(a) The hearing aid is covered by warranty or insurance; or

(b) Repair or reconditioning would be more cost-effective.

(4) Concurrent requests or claims for two separate hearing aids will be treated as a single request or claim for a binaural hearing aid.

(5) Payment for a hearing aid includes the following items:

(a) A cleaning kit;

(b) An initial earmold insert (applicable to behind-the-ear hearing aids); and

(c) One month's supply of batteries.

(6) Payment for hearing aid dispensing includes the following services:

(a) The taking of initial earmold impressions;

(b) Assistance with selection of the hearing aid;

(c) Up to three hours of counseling;

(d) All visits (including travel) necessary for the dispensing and fitting of the hearing aid (regardless of place of service); and

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

(D) Claim payment.

(1) Payment for an analog a hearing aid is the lesser of two least of three figures:

(a) The medicaid maximum amount listed in the appendix to rule 5160-10-01 of the Administrative Code; or

(b) The provider's acquisition cost, which is the sum of the manufacturer's final invoice price and shipping less any discounts received. ; or

(c) The amount the provider customarily charges the general public.

(2) Payment for a digital hearing aid is the lesser of two figures:

(a) A percentage of the medicaid maximum amount listed in the appendix to rule 5160-10-01 of the Administrative Code, determined by the age of the individual:

(i) For an individual younger than twenty-one years of age, one hundred per cent; or

(ii) For an individual twenty-one years of age or older, fifty per cent; or

(b) The provider's usual and customary charge.

(3)(2) Payment for repair of a hearing aid is the submitted charge, which must represent represents one of the following amounts:

(a) If the provider performed the repair, the provider's usual and customary total charge total amount the provider customarily charges the general public; or

(b) If the provider subcontracted the repair, one hundred twenty-five per cent of the amount shown on the invoice sent to the provider.

Notes

Ohio Admin. Code 5160-10-11

Effective: 1/1/2024
Five Year Review (FYR) Dates: 10/17/2023 and 01/01/2029
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 01/01/1980, 03/01/1984, 05/01/1990, 02/01/1993, 12/10/1993, 01/01/1995, 09/01/2005, 12/01/2013, 07/16/2018