Current through Register 1531, September 27, 2024
(A)
Complete Audiological Evaluation.
(1) Payment for a complete audiological
evaluation will be made only if the evaluation is recommended by a
physician;
(2)
Two
Audiologists. The MassHealth agency will pay for two audiologists
working together to perform an evaluation of an individual member under those
circumstances where the knowledge, skills, and experience of the primary
audiologist have identified a need for a second audiologist to aid in
completing the initial test battery, such as for the testing of very young
children or those with other pertinent developmental, physical, cognitive, or
maturational factors. Circumstances warranting the services of two audiologists
must be fully documented in the member's medical record. To receive full
payment, both audiologists must use the appropriate service code and modifier
combination listed in Subchapter 6 of the Audiologist Manual.
The MassHealth agency pays one-half of the total reimbursement for two
audiologists to each individual provider.
(B)
Hearing-aid
Purchase. Payment for a hearing-aid purchase includes the
following:
(1) the hearing aid and standard
accessories and options required for the proper operation of the hearing
aid;
(2) the proper fitting and
instruction in the use, care, and maintenance of the hearing aid;
(3) maintenance, minor repair, and servicing
of the hearing aid that is furnished free of charge to non-MassHealth
patients;
(4) the initial
manufacturer's warranty against loss or damage; and
(5) the loan of a hearing aid to the member
by the audiologist, when necessary.
(C)
Earmold. The
provider may not claim payment for an earmold until the earmold has actually
been delivered to the member. The date of service for the earmold is the date
on which the earmold was delivered to the member. An earmold is not
reimbursable if it is included in the manufacturer's price of the hearing aid
or if the member already has an appropriate earmold. Payment for an earmold
includes the following:
(1) the ear
impression;
(2) the proper fitting
of the earmold; and
(3) any
adjustments that may be needed during the operational life of the
earmold.
(D)
Ear Impression.
(1)
Ear Impression for an ITE/ITC Hearing Aid. Payment for
an ear impression for a hearing aid includes one properly formed ear impression
for each in-the-ear (ITE) or in-the-canal (ITC) hearing aid purchased. The
provider may not claim payment for an ear impression for a hearing aid until
the hearing aid has actually been delivered to the member.
(2)
Ear Impression for an Earmold
for a BTE Hearing Aid. Payment for an ear impression for a hearing
aid includes one properly formed ear impression for each behind-the-ear (BTE)
hearing aid.
(E)
Batteries. Batteries must be new at the time of
purchase.
(F)
Accessories. Payment for accessories and hearing-aid
options includes proper fitting and adjustment of the accessory as needed.
Accessories must be billed separately from the basic hearing-aid
unit.
(G)
Major
Repairs. The provider of a repair service is responsible for the
quality of the workmanship and parts, and for ensuring that the repaired
hearing aid is in proper working condition. The audiologist is responsible for
ensuring that the repaired hearing aid is in proper working condition upon
returning the aid to the member. Payment for a major repair to a hearing aid is
limited to the following conditions.
(1) All
warranties and insurance must have expired.
(2) The hearing aid must be sent directly to
the repair facility or manufacturer that will perform the repair. (The handling
charges of an intermediary are not reimbursable.)
(3) The repair service must include a written
warranty against all defects for a minimum of six months.
(4) A copy of the invoice from the repair
facility or manufacturer for the cost of the repair must be kept in the
member's medical record.
(H)
Office Visits for Evaluation
and Management Services. The MassHealth agency pays for an office
visit for evaluation and management services only when one or more of the
following services is required and is provided as part of the visit:
(1) minor adjustments to the hearing aid to
assure a proper fitting, such as an earmold adjustment, when the provider is
not the provider who initially fit the hearing aid, and the provider who
initially fit the hearing aid is no longer a MassHealth provider;
(2) minor office repairs for which the
provider customarily charges non-MassHealth members;
(3) cleaning of the hearing aid; or
(4) replacement of parts such as, but not
limited to, tubing, hooks, battery doors, and recasing.
(I)
Refitting Services and Other
Professional Services. The MassHealth agency pays for additional
fitting/refitting services only where the hearing aid was dispensed more than
one year prior to the date of service of the refitting services. These
professional services include refitting of the aid, orientation, counseling
with the member or member's family, contact with interpreters, fitting of a
loaner aid, and similar services. Payment for these services must include a
face-to-face encounter with the member.
(J)
Cochlear Implant Service
Contract. The MassHealth agency pays for the following cochlear
implant services:
(1) A service or maintenance
contract from the manufacturer of cochlear implant external components that is
approved by the U.S. Department of Health and Human Services Food and Drug
Administration (FDA), which covers certain costs for repair and replacement
parts for an eligible member's existing cochlear implant external component and
is subject to the provisions of 130 CMR 426.416(J)(2).
(2) The following restrictions apply to the
service contract:
(a) The service contract
must be for a minimum period of one year, paid in full with the enrollment. The
MassHealth agency does not pay for a service contract purchased under an
installment payment plan, where payment in full at enrollment is also an
option.
(b) The service contract,
when available as a combined option, must include repair and replacement
coverage for both the headpiece, controller, and processor.
(c) The service contract is not covered until
the manufacturer's original warranty, which is obtained at the time of initial
implantation, expires.
(d) A copy
of the invoice from the manufacturer for the cost of the service contract must
accompany the claim form.
(e) The
service contract must be between the manufacturer and the MassHealth
participating provider supplying cochlear implant external services.
(K)
Replacement and Repair of Cochlear Implant External
Components.
(1) Replacement of a
cochlear implant processor requires prior authorization in accordance with
130 CMR
426.408. Replacement of a cochlear implant
processor is covered, only when:
(a) the
existing processor is obsolete; that is, the manufacturer no longer supports
repairs on the existing processor; or
(b) the existing processor is lost. A lost
cochlear implant processor will be replaced by the same make/model as the lost
processor, unless the processor is obsolete, in which case it would be
substituted by the replacement model; and
(c) the existing processor is beyond
repair.
(2) Replacement
of cochlear implant external components, other than the cochlear implant
external processor, are covered only when:
(a)
the existing component is lost. A lost cochlear implant component will be
replaced by the same make/mode as the lost component.
(b) the existing processor is beyond
repair.
(3) MassHealth
covers repairs of cochlear implant external components.
(4) The replacement or repair services must
be performed in a cochlear implant clinic.
