CABINET FOR HEALTH AND FAMILY SERVICES

Department for Medicaid Services

Division of Policy and Operations

(As Amended at ARRS, May 13, 2014)

 

††††† 907 KAR 1:039. Hearing Program reimbursement provisions and requirements[Payments for hearing services].

 

††††† RELATES TO: KRS 205.520, 334.010, 334.040, 334.200, 334A.020(5), 42 C.F.R. 447.200, 204

††††† 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[of Medical Assistance]. 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 to qualify for federal Medicaid funds[for the provision of medical assistance to Kentucky's indigent citizenry]. This administrative regulation establishes the reimbursement provisions and requirements for covered audiology services, hearing instruments, and related items provided to a Medicaid recipient who is not enrolled with a managed care organization[method for determining amounts payable by the department for hearing services].

 

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

††††† (2) "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["Comparable instrument" means an instrument falling within the general classifications of fitting type, for example, body, behind-the-ear, in-the-ear, or eyeglasses].

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

††††† (4) ďFederal financial participation" is defined by[in] 42 C.F.R. 400.203.

††††† (5) "Healthcare Common Procedure Coding System" or "HCPCS" means a collection of codes acknowledged by the Centers for Medicare and Medicaid Services (CMS) that represents procedures or time.

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

††††† (7) "Managed care organization" means an entity for which the Department for Medicaid Services has contracted to serve as a managed care organization as defined in 42 C.F.R. 438.2.

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

††††† (9) "Participating audiologist" means an audiologist who:

††††† (a) Is enrolled in the Medicaid Program pursuant to 907 KAR 1:672;

††††† (b) Is currently participating in the Medicaid Program pursuant to 907 KAR 1:671; and

††††† (c) Meets the audiologist requirements established in 907 KAR 1:038.

††††† (10) "Participating specialist in hearing instruments" means a specialist in hearing instruments who:

††††† (a) Is enrolled in the Medicaid Program pursuant to 907 KAR 1:672;

††††† (b) Is currently participating in the Medicaid Program pursuant to 907 KAR 1:671; and

††††† (c) Meets the specialist in hearing instruments requirements established in 907 KAR 1:038.

††††† (11) "Recipient" is defined by KRS 205.8451(9).

††††† (12)[(5)] "Specialist in hearing instruments" is defined by KRS 334.010(9).

††††† (13) "Usual and customary charge" means the uniform amount that a provider bills to the general public for a specific covered benefit.

 

††††† Section 2. General Reimbursement Requirements. (1)(a) For the department to reimburse for a service or item, the requirements of 907 KAR 1:038, Section 2, shall be met.

††††† (2)[service or item shall be:

††††† 1. Provided:

††††† a. To a recipient under the age of twenty-one (21) years, including the month in which the recipient becomes twenty-one (21); and

††††† b. By a provider who is:

††††† (i) Enrolled in the Medicaid Program pursuant to 907 KAR 1:672;

††††† (ii) Currently participating in the Medicaid Program pursuant to 907 KAR 1:671; and

††††† (iii) Authorized to provide the service in accordance with 907 KAR 1:038;

††††† 2. Covered in accordance with 907 KAR 1:038; and

††††† 3. Medically necessary.

††††† (b) In accordance with 907 KAR 17:015, Section 3(3), a provider of a service to an enrollee shall not be required to be currently participating in the Medicaid Program if the managed care organization in which the enrollee is enrolled does not require the provider to be currently participating in the Medicaid Program.

††††† (2)(a) If a procedure is part of a comprehensive service, the department shall:

††††† 1. Not reimburse separately for the procedure; and

††††† 2. Reimburse one (1) payment representing reimbursement for the entire comprehensive service.

††††† (b) A provider shall not bill the department multiple procedures or procedural codes if one (1) CPT code or HCPCS code is available to appropriately identify the comprehensive service provided.

††††† (3) A provider shall comply with:

††††† (a) 907 KAR 1:671;

††††† (b) 907 KAR 1:672; and

††††† (c) All applicable state and federal laws.

††††† (4)(a) If a provider receives any duplicate or overpayment from the department, regardless of reason, the provider shall return the payment to the department.

††††† (b) Failure to return a payment to the department in accordance with paragraph (a) of this subsection may be:

††††† 1. Interpreted to be fraud or abuse; and

††††† 2. Prosecuted in accordance with applicable federal or state law.

††††† (c) Nonduplication of payments and third-party liability shall be in accordance with 907 KAR 1:005.

††††† (d) A provider shall comply with KRS 205.622.

††††† (5)] The department shall not reimburse for:

††††† (a) A service with a CPT code that is not listed on the Department for Medicaid Services Hearing Program Fee Schedule; or

††††† (b) An item with an HCPCS code that is not listed on the Department for Medicaid Services Hearing Program Fee Schedule.

 

††††† Section 3. Audiology Service Reimbursement. The department shall reimburse a participating audiologist for an audiology service at the lesser of the:

††††† (1) Audiologistís usual and customary charge for the service; or

††††† (2) Reimbursement established on the Department for Medicaid Services Hearing Program Fee Schedule for the service.

 

††††† Section 4. Hearing Instrument Reimbursement. (1) The department shall reimburse a participating specialist in hearing instruments or participating audiologist for a hearing instrument at the lesser of the:

††††† (a) Providerís usual and customary charge for the hearing instrument; or

††††† (b) Reimbursement established on the Department for Medicaid Services Hearing Program Fee Schedule for the hearing instrument.

††††† (2) A hearing examination of a recipient by a physician and a recommendation for a hearing instrument for the recipient by an audiologist shall:

††††† (a) Be required for the department to cover a hearing instrument; and

††††† (b) Occur prior to the fitting of a hearing instrument.

††††† (3)(a) Except for an ear mold, an invoice for a hearing instrument, related supply, or accessory shall be submitted with the corresponding claim:

††††† 1. To the department; and

††††† 2. By the participating audiologist or participating specialist in hearing instruments who supplied the hearing instrument, related supply, or accessory.

††††† (b) The department shall not require a participating audiologist or participating specialist in hearing instruments to submit an invoice for an ear mold.

 

††††† Section 5. Ear Mold Reimbursement. (1) The department shall reimburse a participating audiologist or participating specialist in hearing instruments for an ear mold at the lesser of the:

††††† (a) Providerís usual and customary charge for the ear mold; or

††††† (b) Reimbursement established on the Department for Medicaid Services Hearing Program Fee Schedule for the ear mold.

††††† (2) The department shall limit reimbursement for an ear mold, in conjunction with an ear examination, to:

††††† (a) One (1) ear mold per six (6) month period for a child aged three (3) years or under; or

††††† (b) One (1) ear mold per twelve (12) month period for a child who is at least four (4) years of age.

 

††††† Section 6. Reimbursement for Hearing Instrument Batteries. (1) The department shall reimburse a participating audiologist or participating specialist in hearing instruments for a hearing instrument battery at the lesser of the:

††††† (a) Providerís usual and customary charge for the hearing instrument battery; or

††††† (b) Reimbursement established on the Department for Medicaid Services Hearing Program Fee Schedule for the hearing instrument battery.

††††† (2) The departmentís reimbursement for hearing instrument batteries shall be limited to fifty-two (52) batteries per hearing instrument when dispensed with a:

††††† (a) New hearing instrument; or

††††† (b) Replacement hearing instrument.

 

††††† Section 7. Replacement Cord Reimbursement. The department shall reimburse a participating audiologist or participating specialist in hearing instruments for a replacement cord at the lesser of the:

††††† (1) Providerís usual and customary charge for the replacement cord; or

††††† (2) Reimbursement established on the Department for Medicaid Services Hearing Program Fee Schedule for the replacement cord.

 

††††† Section 8. Hearing Instrument Repair Reimbursement. The department shall reimburse a participating audiologist or participating specialist in hearing instruments for hearing instrument repair at the lesser of the:

††††† (1) Providerís usual and customary charge for the hearing instrument repair; or

††††† (2) Reimbursement established on the Department for Medicaid Services Hearing Program Fee Schedule for the hearing instrument repair.

 

††††† Section 9. Not Applicable to Managed Care Organizations. A managed care organization shall not be required to reimburse the same amount as established in this administrative regulation for a service or item covered pursuant to 907 KAR 1:038 and this administrative regulation.

 

††††† Section 10. Federal Approval and Federal Financial Participation. The departmentís reimbursement for services pursuant to this administrative regulation shall be contingent upon:

††††† (1) Receipt of federal financial participation for the reimbursement; and

††††† (2) Centers for Medicare and Medicaid Servicesí approval for the reimbursement.

 

††††† Section 11.[Section 2. Reimbursement to an Audiologist. The department shall reimburse a participating audiologist at usual and customary actual billed charges up to the fixed upper limit per procedure established by the department at sixty-five (65) percent of the median billed charge using 1989 calendar year billed charges.

 

††††† Section 3. Hearing Instrument Reimbursement. (1) If a manufacturer of a hearing instrument billed to the department submits a price schedule which includes the manufacturerís invoice price of the hearing instrument, the department shall reimburse the participating specialist in hearing instruments at the lesser of:

††††† (a) The manufacturerís invoice price plus a professional fee of:

††††† 1. $150 for the first (one (1) ear) hearing instrument; and

††††† 2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two (2) hearing instruments are dispensed on the same date;

††††† (b) The actual specialist in hearing instrumentsí cost plus a professional fee of:

††††† 1. $150 for the first (one (1) ear) hearing instrument; and

††††† 2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two (2) hearing instruments are dispensed on the same date; or

††††† (c) The suggested retail price submitted by the manufacturer for the hearing instrument.

††††† (2) If a manufacturer of a hearing instrument billed to the department has not submitted a price schedule which includes the manufacturerís invoice price for the hearing instrument, the department shall reimburse the participating specialist in hearing instruments at the lesser of:

††††† (a) The lowest price submitted for a comparable hearing instrument plus a professional fee of:

††††† 1. $150 for the first (one (1) ear) hearing instrument; and

††††† 2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two

††††† (2) hearing instruments are dispensed on the same date;

††††† (b) The actual specialist in hearing instrumentsí cost plus a professional fee of:

††††† 1. $150 for the first (one (1) ear) hearing instrument; and

††††† 2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two (2) hearing instruments are dispensed on the same date; or

††††† (c) The lowest suggested retail price submitted by a manufacturer for a comparable instrument.

 

††††† Section 4. Replacement Cord Reimbursement. The department shall reimburse for a replacement cord at the specialist in hearing instrumentsí cost plus a professional fee set at $21.50.

 

††††† Section 5. Hearing Instrument Repair Reimbursement. The department shall reimburse a specialist in hearing instruments for a hearing instrument repair:

††††† (1) On the basis of the manufacturer's charge for repair or replacement of parts;

††††† (2) Plus the specialist in hearing instrumentsí cost for postage and insurance relative to the repair;

††††† (3) Plus a professional fee of $21.50; and

††††† (4) Not to exceed the price of a new hearing instrument.

 

††††† Section 6.] Appeals. A provider may appeal a department decision as to the application of this administrative regulation in accordance with 907 KAR 1:671.

 

††††† Section 12. Incorporation by Reference. (1) The "Department for Medicaid Services Hearing Program Fee Schedule", December 2013, is incorporated by reference.

††††† (2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Department for Medicaid Services, 275 East Main Street, Frankfort, Kentucky, Monday through Friday, 8 a.m. to 4:30 p.m. or online at the departmentís Web site at http://www.chfs.ky.gov/dms/incorporated.htm.

 

LAWRENCE KISSNER, Commissioner

AUDREY TAYSE HAYNES, Secretary

††††† APPROVED BY AGENCY: December 19, 2013

††††† FILED WITH LRC: December 26, 2013 at 4 p.m.

††††† CONTACT PERSON: Tricia Orme, tricia.orme@ky.gov, Office of Legal Services, 275 East Main Street 5 W-B, Frankfort, Kentucky 40601, phone (502) 564-7905, fax (502) 564-7573.