Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter A - PURCHASED HEALTH SERVICES
Division 15 - HEARING AID SERVICES
Section 354.1231 - Benefits and Limitations
Universal Citation: 1 TX Admin Code ยง 354.1231
Current through Reg. 49, No. 38; September 20, 2024
(a) Benefits. Reimbursement for hearing aid services available through the Texas Medical Assistance (Medicaid) Program shall be provided in accordance with federal regulations found at 42 CFR Chapter IV, Subchapter C, Medical Assistance Programs, and the provisions and procedures found elsewhere in this chapter. The following hearing aid services shall be reimbursed through the Texas Medicaid Program:
(1) physician, or,
under physician delegation, a nurse practitioner, clinical nurse specialist, or
physician assistant, examination to determine the medical necessity for a
hearing aid;
(2) hearing aid
evaluations;
(3) hearing aids
(monaural or binaural) and hearing aid repairs;
(4) replacement batteries and related hearing
aid supplies;
(5) initial fitting,
dispensing, and post-fitting check of the hearing aid(s); and
(6) first and second revisits to assess the
recipient's adaptation to the hearing aid(s) and the functioning of the
instrument(s).
(b) Limitations and exclusions. All authorized hearing aid providers, as described in §354.1233 of this division (relating to Requirements for Hearing Aid Services), must comply with the following conditions and limitations established by the Texas Health and Human Services Commission (HHSC).
(1) Hearing aid services are available to
persons who are eligible for Medicaid services.
(2) An individual using a hearing aid before
becoming eligible for Medicaid benefits may have a hearing aid evaluation
conducted by an approved hearing aid services provider after becoming eligible
for Medicaid. Medicaid reimbursement for a new hearing aid shall be denied if
the provider concludes, based upon the evaluation findings, that the
recipient's present hearing aid adequately compensates for the degree of
hearing loss.
(3) Providers may not
submit a hearing aid evaluation claim to HHSC unless the Medicaid recipient
meets the eligibility criteria in §354.1233(c).
(4) Repairs are limited to one per year per
hearing aid. Additional repairs require prior authorization.
(5) Replacement of a hearing aid may be
considered when loss or irreparable damage has occurred. Replacement of a
hearing aid requires prior authorization. Replacement will not be authorized in
situations where the equipment has been abused or neglected.
(6) Hearing aids may be replaced once every
five years.
(7) Hearing aid
services do not include auditory training, speechreading, or other types of
rehabilitative services.
(8)
Hearing aids are limited to eligible recipients who meet medical necessity
criteria as defined by HHSC or its designee, which includes an air conduction
puretone average (500 Hz, 1000 Hz, 2000 Hz) in the better ear of 35 dB hearing
loss (HL) or greater.
(9)
Recipients under the age of 21 meet the criteria for binaural aids if they meet
the conditions for a monaural hearing aid and have at least a 35 dB hearing
loss in both ears.
(10) Recipients
under the age of 21 that do not meet the criteria listed in this section may
submit a request for authorization through the Texas Health Steps Comprehensive
Care Program (THSteps-CCP).
(11)
Coverage for recipients age 21 and older who meet the medical criteria as
defined by HHSC or its designee and have hearing loss in both ears is limited
to one hearing aid.
(12) Coverage
is not available for recipients age 21 and older who have hearing loss in only
one ear.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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