907 KAR 1:038E - Hearing Program coverage provisions and requirements
RELATES TO: KRS 205.520, 205.622, 205.8451(9), 334.010(4), (9), 334A.020(5), 334A.030, 42 C.F.R. 400.203, 438.20, 457.310, 42 U.S.C. 1396a, b, d, 1396r-6
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 to qualify for federal Medicaid funds. This administrative regulation establishes the Medicaid Program provisions and requirements regarding the coverage of audiology services and hearing instruments.
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.
(3) "Department" means
the Department for Medicaid Services or its designee.
(4) "Enrollee" means a recipient who is
enrolled with a managed care organization.
(5) "Federal financial participation" is
defined by 42 C.F.R.
400.203.
(6) "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
items.
(7) "Hearing instrument" is
defined by KRS
334.010(4).
(8) "Managed care organization" means an
entity for which the Department for Medicaid Services has contracted to serve
as a managed care organization as defined by
42 C.F.R.
438.2.
(9) "Medically necessary" or "medical
necessity" means that a covered benefit is determined to be needed in
accordance with
907 KAR 3:130.
(10) "Recipient" is defined by
KRS
205.8451(9).
(11) "Specialist in hearing instruments" is
defined by KRS
334.010(9).
Section 2. General Requirements.
(1)
(a) For
the department to reimburse for a service or item, the service or item shall:
1. Be provided:
a. To a recipient; and
b. By a provider who is:
(i) Enrolled in the Medicaid Program pursuant
to 907 KAR 1:672;
(ii) Except as provided by paragraph (b) of
this subsection, currently participating in the Medicaid Program pursuant to
907 KAR 1:671; and
(iii) Authorized to provide the service in
accordance with this administrative regulation;
2. Be covered in accordance with this
administrative regulation;
3. Be
medically necessary;
4. Have a CPT
code or HCPCS code that is listed on the most current Kentucky Medicaid
Audiology Fee Schedule, posted on the department Web site at:
https://chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
Any fee schedule posted shall comply with all relevant existing rate
methodologies utilized by the department and established by state and federal
law. As appropriate and relevant, the department shall utilize the Medicaid
Physician Fee Schedule established in
907 KAR 3:010 to inform and
populate the Audiology Fee Schedule; and
5. Audiology service limits shall be as
established on the Kentucky Medicaid Audiology Fee Schedule as available at:
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
(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 fee-for-service 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
payment 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)
(a) An
in-state audiologist shall:
1. Maintain a
current, unrevoked, and unsuspended license in accordance with KRS Chapter
334A;
2. Before initially enrolling
in the Kentucky Medicaid Program, submit proof of the license referenced in
subparagraph 1. of this paragraph to the department; and
3. Annually submit proof of the license
referenced in subparagraph 1. of this paragraph to the department.
(b) An out-of-state audiologist
shall:
1. Maintain a current, unrevoked, and
unsuspended license to practice audiology in the state in which the audiologist
is licensed;
2. Before initially
enrolling in the Kentucky Medicaid Program, submit proof of the license
referenced in subparagraph 1. of this paragraph to the department;
3. Annually submit proof of the license
referenced in subparagraph 1. of this paragraph to the department;
4. Maintain a Certificate of Clinical
Competence issued to the audiologist by the American Speech-Language-Hearing
Association; and
5. Before
enrolling in the Kentucky Medicaid Program, submit proof of having a
Certificate of Clinical Competence issued to the audiologist by the American
Speech-Language-Hearing Association.
(c) If an audiologist fails to comply with
paragraph (a) or (b) of this subsection, as applicable based on if the
audiologist is in-state or out-of-state, the:
1. Audiologist shall be ineligible to be a
Kentucky Medicaid Program provider; and
2. Department shall not reimburse for any
service or item provided by the audiologist effective with the date the
audiologist fails or failed to comply.
(6)
(a) An
in-state specialist in hearing instruments shall:
1. Maintain a current, unrevoked, and
unsuspended license issued by the Kentucky Licensing Board for Specialists in
Hearing Instruments;
2. Before
initially enrolling in the Kentucky Medicaid Program, submit proof of the
license referenced in subparagraph 1. of this paragraph to the
department;
3. Annually submit
proof of the license referenced in subparagraph 1. of this paragraph to the
department;
4. Maintain a
Certificate of Clinical Competence issued to the specialist in hearing
instruments by the American Speech-Language-Hearing Association; and
5. Before enrolling in the Kentucky Medicaid
Program, submit proof of having a Certificate of Clinical Competence issued to
the specialist in hearing instruments by the American Speech-Language-Hearing
Association.
(b) An
out-of-state specialist in hearing instruments shall:
1. Maintain a current, unrevoked, and
unsuspended license issued by the licensing board with jurisdiction over
specialists in hearing instruments in the state in which the license is
held;
2. Before initially enrolling
in the Kentucky Medicaid Program, submit proof of the license referenced in
subparagraph 1. of this paragraph to the department;
3. Annually submit proof of the license
referenced in subparagraph 1 of this paragraph to the department;
4. Maintain a Certificate of Clinical
Competence issued to the specialist in hearing instruments by the American
Speech-Language-Hearing Association; and
5. Before enrolling in the Kentucky Medicaid
Program, submit proof of having a Certificate of Clinical Competence issued to
the specialist in hearing instruments by the American Speech-Language-Hearing
Association.
(c) If a
specialist in hearing instruments fails to comply with paragraph (a) or (b) of
this subsection, as applicable based on if the specialist in hearing
instruments is in-state or out-of-state, the:
1. Specialist in hearing instruments shall be
ineligible to be a Kentucky Medicaid Program provider; and
2. Department shall not reimburse for any
service or item provided by the specialist in hearing instruments effective
with the date the specialist in hearing instruments fails or failed to
comply.
Section
3. Audiology Services.
(1)
Audiology service coverage shall be limited to one (1) complete hearing
evaluation per calendar year.
(2)
Unless a recipient's health care provider demonstrates, and the department
agrees, that an additional hearing instrument evaluation is medically
necessary, a hearing instrument evaluation shall:
(a) Include three (3) follow-up visits, which
shall be:
1. Within the six (6) month period
immediately following the fitting of a hearing instrument; and
2. Related to the proper fit and adjustment
of the hearing instrument; and
(b) Include one (1) additional follow-up
visit, which shall be:
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)
(a) A
referral by a physician to an audiologist shall be required for an audiology
service.
(b) The department shall
not cover an audiology service if a referral from a physician to the
audiologist was not made.
(c) An
office visit with a physician shall not be required prior to the referral to
the audiologist for the audiology service.
Section 4. Hearing Instrument Coverage.
(1) 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; and
2. Available through a Medicaid-participating
specialist in hearing instruments; and
(b) Except as provided by Section 5(3) of
this administrative regulation, not exceed $1,200 per ear every thirty-six (36)
months.
(2) Hearing
instrument coverage may include the replacement or upgrading of a hearing
instrument battery if the upgrade is cost-effective or extends the service life
of the hearing instrument.
Section
5. Replacement of a Hearing Instrument.
(1) The department shall reimburse for the
replacement of a hearing instrument if:
(a) A
loss of the hearing instrument necessitates replacement;
(b) Extensive damage has occurred
necessitating replacement;
(c)
Medical necessity demonstrates that new or improved technology would
significantly increase hearing; or
(d) A medical condition necessitates the
replacement of the previously prescribed hearing instrument in order to
accommodate a change in hearing loss.
(2) If replacement of a hearing instrument is
necessary within twelve (12) months of the original fitting, the replacement
hearing instrument shall be fitted upon the signed and dated recommendation
from an audiologist.
(3) If
replacement of a hearing instrument becomes necessary beyond twelve (12) months
from the original fitting:
(a) The recipient
shall be examined by a physician with a referral to an audiologist;
and
(b) The recipient's hearing
loss shall be re-evaluated by an audiologist.
Section 6. Noncovered services. The
department shall not reimburse for:
(1) A
routine screening of a group of individuals for identification of a hearing
problem;
(2) Hearing therapy except
as covered through the six (6) month adjustment counseling following the
fitting of a hearing instrument;
(3) Lip reading instructions except as
covered through the six (6) month adjustment counseling following the fitting
of a hearing instrument;
(4) A
service for which the recipient has no obligation to pay and for which no other
person has a legal obligation to provide or to make payment;
(5) A telephone call;
(6) A service associated with investigational
research; or
(7) A replacement of a
hearing instrument for the purpose of incorporating a recent improvement or
innovation unless the replacement results in appreciable improvement in the
recipient's hearing ability as determined by an audiologist.
Section 7. Equipment.
(1) Equipment used in the performance of a
test shall meet the current standards and specifications established by the
American National Standards Institute.
(2)
(a) A
provider shall ensure that any audiometer used by the provider or provider's
staff shall:
1. Be checked at least once per
year to ensure proper functioning; and
2. Function properly.
(b) A provider shall:
1. Maintain proof of calibration and any
repair, if any repair occurs; and
2. Make the proof of calibration and repair,
if any repair occurs, available for departmental review upon the department's
request.
Section
8. Service and equipment limits may be exceeded by prior
authorization for children under twenty-one (21) if medically
necessary.
Section 9. Federal
Approval and Federal Financial Participation. The department's coverage of
services pursuant to this administrative regulation shall be contingent upon:
(1) Receipt of federal financial
participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
Section 10. Appeal Rights. An appeal of a
negative action regarding a Medicaid recipient who is:
(1) Enrolled with a managed care organization
shall be in accordance with
907 KAR 17:010; or
(2) Not enrolled with a managed care
organization shall be in accordance with
907 KAR
1:563.
Section 11. Incorporation by Reference.
(1) "KY Medicaid Audiology Fee Schedule",
April 2023, is incorporated by reference.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m.
to 4:30 p.m.; or
(b) Online at the
department's Web site located at
https://www.chfs.ky.gov/agencies/dms/Pages/feesrates.aspx.
Section 12. This
administrative regulation has been found deficient by the Administrative
Regulation Review Subcommittee on May 9, 2023.
Notes
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)
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