907 KAR 1:038. Hearing and Vision Program services.

 

      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 for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the hearing services and vision services for which payment shall be made by the Medicaid Program.

 

      Section 1. Definitions. (1) "Audiologist" is defined by KRS 334A.020(5).

      (2) "Comprehensive choices" means a benefit plan for an individual who:

      (a) Meets the nursing facility patient status criteria established in 907 KAR 1:022;

      (b) Receives services through either:

      1. A nursing facility in accordance with 907 KAR 1:022;

      2. The Acquired Brain Injury Waiver Program in accordance with 907 KAR 3:090;

      3. The Home and Community Based Waiver Program in accordance with 907 KAR 1:160; or

      4. The Model Waiver II Program in accordance with 907 KAR 1:595; and

      (c) Has a designated package code of F, G, H, I, J, K, L, M, O, P, Q, or R.

      (3) "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.

      (4) "Department" means the Department for Medicaid Services or its designee.

      (5) "Emergency" means that a condition or situation requires an emergency service pursuant to 42 C.F.R. 447.53.

      (6) "Family choices" means a benefit plan for an individual who:

      (a) Is covered pursuant to:

      1. 42 U.S.C. 1396a(a)(10)(A)(i)(I) and 1396u-1;

      2. 42 U.S.C. 1396a(a)(52) and 1396r-6 (excluding children eligible under Part A or E of title IV, codified as 42 U.S.C. 601 to 619 and 670 to 679b);

      3. 42 U.S.C. 1396a(a)(10)(A)(i)(IV) as described in 42 U.S.C. 1396a(l)(1)(B);

      4. 42 U.S.C. 1396a(a)(10)(A)(i)(VI) as described in 42 U.S.C. 1396a(l)(1)(C);

      5. 42 U.S.C. 1396a(a)(10)(A)(i)(VII) as described in 42 U.S.C. 1396a(l)(1)(D); or

      6. 42 C.F.R. 457.310; and

      (b) Has a designated package code of 2, 3, 4, or 5.

      (7) "Global choices" means the department's default benefit plan, consisting of individuals designated with a package code of A, B, C, D, or E and who are included in one (1) of the following populations:

      (a) Caretaker relatives who:

      1. Receive K-TAP benefits and are deprived due to death, incapacity, or absence;

      2. Do not receive K-TAP benefits and are deprived due to death, incapacity, or absence; or

      3. Do not receive K-TAP benefits and are deprived due to unemployment;

      (b) Individuals aged sixty-five (65) and over who receive SSI benefits and:

      1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022; or

      2. Receive SSP benefits and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

      (c) Blind individuals who receive SSI benefits and:

      1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022; or

      2. SSP benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

      (d) Disabled individuals who receive SSI benefits and:

      1. Do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022, including children; or

      2. SSP benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

      (e) Individuals aged sixty-five (65) and over who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status criteria in accordance with 907 KAR 1:022;

      (f) Blind individuals who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status in accordance with 907 KAR 1:022;

      (g) Disabled individuals who have lost SSI or SSP benefits, are eligible for "pass through" Medicaid benefits, and do not meet nursing facility patient status in accordance with 907 KAR 1:022;

      (h) Pregnant women; or

      (i) Medicaid works individuals.

      (8) "Hearing instrument" is defined by KRS 334.010(4).

      (9) "Medically necessary" or "medical necessity" means that a covered benefit is determined to be needed in accordance with 907 KAR 3:130.

      (10) "Nonemergency" means that a condition or situation does not require an emergency service pursuant to 42 C.F.R. 447.53

      (11) "Optimum choices" means a benefit plan for an individual who:

      (a) Meets the intermediate care facility for individuals with an intellectual disability patient status criteria established in 907 KAR 1:022;

      (b) Receives services through either:

      1. An intermediate care facility for individuals with an intellectual disability in accordance with 907 KAR 1:022; or

      2. The Supports for Community Living Waiver Program in accordance with 907 KAR 1:145; and

      (c) Has a designated package code of S, T, U, V, W, X, Z, 0, or 1.

      (12) "Specialist in hearing instruments" is defined by KRS 334.010(9).

 

      Section 2. Hearing Services. (1) All hearing coverage shall be:

      (a) Limited to an individual under age twenty-one (21); and

      (b) Provided in accordance with the Hearing Program Manual.

      (2) Unless a recipient's health care provider demonstrates that services in excess of the limitations established in this subsection are medically necessary, reimbursement for services provided by an audiologist licensed pursuant to KRS 334A.030 to a recipient shall be limited to:

      (a) The following procedures which shall be covered only if a recipient is referred by a physician to an audiologist licensed pursuant to KRS 334A.030:

Code

Procedure

92552

Pure Tone audiometry (threshold); air only

92555

Speech audiometry threshold

92556

Speech audiometry threshold; with speech recognition

92557

Comprehensive audiometry evaluation

92567

Tympanometry

92568

Acoustic reflex testing

92579

Visual reinforcement audiometry

92585

Auditory evoked potentials

92587

Evoked otoacoustic emissions

92588

Complete or diagnostic evaluation (comparison of transient or distortion product otoacoustic emissions at multiple levels and frequency)

92541

Spontaneous nystagmus test

92542

Positional nystagmus test

92543

Caloric vestibular test

92544

Optokinetic nystagmus test

92545

Oscillating tracking test

92546

Sinusodial vertical axis rotational testing

92547

Use of vertical electrodes

 

      (b) Complete hearing evaluation;

      (c) Hearing instrument evaluation;

      (d) Three (3) follow-up visits that shall be:

      1. Within the six (6) month period immediately following fitting of a hearing instrument; and

      2. Related to the proper fit and adjustment of the hearing instrument; and

      (e) One (1) additional follow-up visit that is:

      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) Hearing instrument benefit coverage shall:

      (a) Be for a hearing instrument model that is:

      1. Recommended by an audiologist licensed pursuant to KRS 334A.030;

      2. Available through a Medicaid-participating specialist in hearing instruments;

      (b) 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 3. Vision Program Services. (1) Vision program coverage shall be limited to:

      (a) A prescription service;

      (b) A repair service made to a frame;

      (c) A diagnostic service provided by:

      1. An ophthalmologist; or

      2. An optometrist to the extent the optometrist is licensed to perform the service.

      (2) Eyeglass coverage shall:

      (a) Be limited to a recipient who is under age twenty-one (21); and

      (b) Not exceed:

      1. $200 per year for a recipient in the global choices benefit package; or

      2. $400 per year for a recipient in the comprehensive choices, family choices, or optimum choices benefit package.

      (3) To be covered:

      (a) A service designated as a physical medicine and rehabilitation service CPT code shall require prior authorization if provided to a recipient age twenty-one (21) or over;

      (b) A radiology service specified in 907 KAR 3:005, Section 5, shall require prior authorization regardless of a recipient's age;

      (c) A service shall be provided in accordance with the Vision Program Manual; and

      (d) A lens shall be polycarbonate and scratch coated.

 

      Section 4. Appeal Rights. (1) An appeal of a negative action regarding a Medicaid recipient shall be in accordance with 907 KAR 1:563.

      (2) An appeal of a negative action regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

      (3) An appeal of a negative action regarding a Medicaid provider shall be in accordance with 907 KAR 1:671.

 

      Section 5. Incorporation by Reference. (1) The following material is incorporated by reference:

      (a) "The Vision Program Manual", October 2007 edition, Department for Medicaid Services; and

      (b) "The Hearing Program Manual", October 2007 edition, Department for Medicaid Services.

      (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. (Recodified from 904 KAR 1:038, 6-10-86; Am. 18 Ky.R. 1625; eff. 1-10-92; 20 Ky.R. 1714; eff. 2-2-94; 23 Ky.R. 4009; 24 Ky.R. 119; eff. 6-18-97; 25 Ky.R. 1254; 1660; eff. 1-19-99; 28 Ky.R. 944; 1404; eff. 12-19-2001; 33 Ky.R. 594; 1377; 1560; eff. 1-5-07; 34 Ky.R. 1820; 2110; eff. 4-4-08; TAm 7-16-2013.)