Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.520,
334.010,
334.040,
334.200,
334A.020(5),
42 C.F.R.
447.200, 204
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 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.
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) "Federal financial participation" is
defined by
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) "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) For the department to reimburse for a
service or item, the requirements of
907
KAR 1:038, Section 2, shall be met.
(2) 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) Audiologist's 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) Provider's 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)
Provider's 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) Provider's 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 department's 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) Provider's 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) Provider's 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 department's 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
Services' approval for the reimbursement.
Section 11. 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 department's Web
site at
http://www.chfs.ky.gov/dms/incorporated.htm.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3)