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 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 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.
(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, and limitations.
(1)
The provider must
keep on file 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 disposable
hearing aid; and
(c)
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 vihearing aid (regardless of place of service);
andsits (including travel) necessary for the dispensing and fitting of the
(e)
All service calls and follow-up visits during the warranty
period.
(D)
Claim
payment.
(1)
Payment for an analog hearing aid is the lesser of two
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.
(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)
Payment for
repair of a hearing aid is the submitted charge, which must represent one of
the following amounts:
(a)
If the provider performed the repair, the provider's
usual and customary total charge; 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.
Replaces: 5160-10-11
Notes
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
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