37.86.802    HEARING AID SERVICES, REQUIREMENTS, AND LIMITATIONS

(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) Medicaid payment for purchase of hearing aids will be made only to a licensed hearing aid dispenser or audiologist for Medicaid covered services provided in accordance with all applicable Medicaid requirements and within the scope of practice permitted under the dispenser's license.

(3) A hearing aid may be covered under the Medicaid program if:

(a) the recipient has been referred by a physician or mid-level practitioner for an audiological examination and the physician or mid-level practitioner has determined that there is no medical reason for which a hearing aid would not be effective in correcting the recipient's hearing loss;

(b) the examination by a licensed audiologist results in a determination that a hearing aid or aids are needed; and

(c) the following criteria are met:

(i) for persons over 21 years of age, the audiological examination results show that there is an average pure tone loss of at least 40 decibels for each of the frequencies of 500, 1000, 2000, and 3000 Hertz in the better ear and word recognition or speech discrimination scores obtained at a level to ensure pb max. The following criteria shall apply to adults aged 21 years or older for binaural hearing aids:

(A) the two frequency average at 1khz and 2khz must be greater than 40db in both ears;

(B) the two frequency average at 1khz and 2khz must be less than 90db in both ears;

(C) the two frequency average at 1khz and 2khz must have an interaural difference of less than 15db;

(D) the interaural word recognition or speech discrimination score must have a difference of not greater than 20%;

(E) demonstrated success in using a monaural hearing aid for at least six months; and

(F) documented need to understand speech with a high level comprehension based on an educational or vocational need.

(ii) for persons under 21 years of age, the department or its designee determines after review of the audiology report that the hearing aid would be appropriate for the person. Persons under 21 years of age will be evaluated under the early periodic screening and testing program.

(d) the original hearing aid no longer meets the needs of the individual, and a new hearing aid is determined to be medically necessary by a licensed audiologist.

(4) The audiologist shall indicate in a written report whether in his or her professional opinion a hearing aid is required for the recipient. The report shall also indicate the type of hearing aid required by the recipient and whether monaural or binaural hearing aids are required. The audiologist's report will be prepared in accordance with the format described in the audiologists' provider manual.

(5) A claim for coverage of a hearing aid must be approved in writing by the department or its designee prior to the provision of the service. Copies of the physician's referral and audiologist's report must be submitted with the claim.

(6) The date of service is defined as the date the hearing aid(s) is ordered by the dispenser.

(7) For individuals age 21 or over, a hearing aid purchased by Medicaid will be replaced no more than once in a five year period and only if:

(a) the original hearing aid has been irreparably broken after the one year warranty period or has been lost;

(b) the provider's records document the loss or broken condition of the original hearing aid; and

(c) the hearing loss criteria specified in this rule continue to be met.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-141, MCA; NEW, 1980 MAR p. 973, Eff. 3/14/80; AMD, 1987 MAR p. 895, Eff. 7/1/87; AMD, 1988 MAR p. 596, Eff. 3/25/88; AMD, 1988 MAR p. 758, Eff. 4/15/88; AMD, 1990 MAR p. 1326, Eff. 7/13/90; AMD, 1998 MAR p. 2168, Eff. 8/14/98; AMD, 1999 MAR p. 1379, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2009 MAR p. 2485, Eff. 1/1/10; AMD, 2011 MAR p. 2293, Eff. 10/28/11.