Medicaid Rules and Fees
The Medicaid Division of the Texas Health and Human Services Commission has finalized the rules and fees governing the dispensing of hearing aids to Medicaid patients.
Effective December 2, 2008
(final publication in Texas Register)
Reimbursement Fees For
Hearing Aids, Repairs, Batteries and Dispensing Services
Effective July 1 and December 2, 2008
Updated July 1 ,2010
In addition, the state's Medicaid administrator, Texas Medicaid & Healthcare Partnership (TMHP), has issued its administrative policies to implement the new Medicaid rules.
TMHP Benefit Criteria For Hearing Devices and Services
Effective December 2, 2008
Below is a brief summary of the final rules that will become effective December 2, 2008. All members who are qualified Medicaid providers are strongly urged to read the final rules and TMHP policies completely to determine how these new provisions affect your operations.
- Dispensers will be reimbursed for monaural fittings if the patient's air conduction puretone average (500 Hz, 1000 Hz, 2000 Hz) in the better ear is 35 dB hearing loss or greater. (used to be 45 dB or greater)
- Dispensers will be reimbursed for binaural fittings in all cases where the patient meets the conditions for a monaural hearing aid and has at least a 35 dB hearing loss in both ears. (use to be only legally blind patients were eligible for binaural fittings)
Recipients of a monaural hearing aid within the last five years can receive the second hearing aid to complete the binaural fitting, provided the recipient qualifies for a binaural fitting under the final rules. The replacement date is based on one hearing aid for the left ear every five rolling years and one hearing aid for the right ear every five rolling years.
- Hearing aid repairs are now a reimbursable benefit. Repairs are limited to one repair or modification per year after the 12-month manufacturer's warranty period has expired. Additional repairs beyond one year require prior authorization from TMHP and will be considered with documentation supporting the need for the requested repair.
- Qualified recipients are now allowed to replace their hearing aids every five years, instead of the previous six year term.
- Replacement of a hearing aid will be considered when loss or irreparable damage has occurred. This requires prior authorization. Replacement will not be be authorized when the equipment has been abused or neglected by the client, the client's family, or the caregiver.
- Hearing aid batteries and related supplies are now a reimbursable benefit. However, the final rules do not define "related supplies" and no specific reimbursement fees for "related supplies" have been adopted or published.
- Replacement of hearing aid batteries may be reimbursed with prior authorization.
- Qualified providers are no longer be required to dispense hearing aids manufactured in the United States.
1. Beginning Dec. 2, 2008, recipients of a monaural hearing aid within the last five years can receive the second hearing aid to complete the binaural fitting, provided the recipient qualifies for a binaural fitting under the final rules (see #2 above). Medicaid considers the fitting of the "second" hearing aid to be a monaural fitting that should be billed under the applicable monaural code. When billing for hearing aids in this manner, Modifier LT (for left ear) or Modifier RT (for right ear) must be included on the claim with the hearing aid procedure code.
2. Medicaid considers a "binaural fitting" to be the fitting of two hearing aids of the same make, model, and kind (i.e., BTE, ITE, ITC, CIC) at the same time. When fitting hearing aids in this manner, providers should use the binaural codes.
3. Medicaid considers the fitting of two hearing aids at the same time that are not the same make, model, and kind (i.e., BTE, ITE, ITC, CIC) to be two separate monaural fittings, billed under two separate monaural codes, with Modifier LT (for left ear) and Modifier RT (for right ear) included on the claim with the procedure codes.