PURPOSE: This rule is to establish the regulatory basis for the administration of the Hearing Aid Program, including the method of purchasing hearing aids; designation of professional persons who may perform the medical ear examination and testing; and the method of reimbursement for the aids and related services. More specific details of the conditions for provider participation, criteria and methodology of provider reimbursement, participant eligibility and amount, duration and scope of services covered are included in the provider program manual.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Administration. The Hearing Aid Program shall be administered by the Department of Social Services, MO HealthNet Division. The services and items covered and not covered, the program limitations and the maximum allowable fees for all covered services shall be determined by the Department of Social Services, MO HealthNet Division through the hearing aid manual and hearing aid bulletins, which are incorporated by reference and made a part of this rule, as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at www.dss.mo.gov/mhd, April 15, 2008. This rule does not incorporate any subsequent amendments or additions.
2. (2) Persons Eligible. The MO HealthNet Program pays for approved MO HealthNet services for hearing aid services when furnished within the provider’s scope of practice to MO HealthNet eligible needy children or persons receiving MO HealthNet under a category of assistance for pregnant women or the blind. The participant must be eligible on the date the service is furnished. Participants may have specific limitations for hearing aid services according to the type of assistance for which they have been determined eligible. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the provider program manual. The provider shall ascertain the patient’s MO HealthNet and managed care or other lock-in status before any service is performed. The participant’s eligibility shall be verified in accordance with methodology outlined in the provider program manual.
3. (3) Prior Authorization of Hearing Aids. Effective for service dates November 1, 1989 and thereafter, all hearing aids and related services will require prior authorization with the exception of audiological testing, post-fitting evaluations, post-fitting adjustments, repairs to hearing aids no longer under warranty and special tests for ruling out retrocochlear involvement.
4. (4) Audiological Requirements. An audiological examination must be performed by an audiologist, hearing aid dealer/fitter, or physician (MD or DO) prior to the submission of a Prior Authorization Request form. This testing, when administered for the purpose of prescribing a hearing aid, will be reimbursed by the MO HealthNet program. Audiological testing performed in relation to a medical or surgical diagnosis or treatment for hearing deficits or related medical problems for purposes other than determining the need for a hearing aid is a noncovered service and is not reimbursable by the MO HealthNet Hearing Aid Program. The audiological tests for a hearing aid must include, at a minimum, air conduction thresholds, bone conduction thresholds (with masking when necessary), speech reception thresholds and speech discrimination scores. The results obtained from these basic audiological tests must be clear and internally consistent, and must demonstrate that a hearing aid is needed, that it will benefit the participant and will support the recommendation of which ear is to be fitted. Testing must be provided in accordance with sound professional practice and the standards under which the provider is licensed.
5. (5) Hearing Loss (HL) Requirement. A participant’s pure-tone average (PTA) must be thirty decibels (30dB) HL or greater in the better ear to qualify for a hearing aid. The PTA is the average air-conduction threshold for five hundred (500), one thousand (1,000), and two thousand (2,000) Hertz (Hz) measured with an earphone. A participant’s speech discrimination must be at least forty 13 CSR 70-45

percent (40%) without visual cues in the ear to be aided to qualify for a hearing aid. The speech discrimination is measured with an earphone using a CID W-22 word list or equivalent. The speech discrimination test materials that are used must be specified.

1. (6) Medical Ear Examination Requirements. The participant must receive a medical ear examination for pathology or disease by a physician licensed as an MD or DO. The medical ear examination must be performed within six (6) months prior to the date a hearing aid is dispensed.
2. (7) Obtaining and Fitting the Aid. Only after receipt of an approved Prior Authorization Request form should the provider proceed with the fitting and dispensing of the hearing aid.
3. (8) Post-fitting Evaluation. A post-fitting evaluation will be performed no sooner than fourteen (14) days or later than thirty (30) days after the hearing aid is dispensed. If the hearing aid is not providing adequate and substantial correction of the loss, reimbursement will not be made for the hearing aid.
4. (9) Reimbursement for Hearing Aids and Related Services. Payment will be made for each unit of service or item provided in accordance with the fee schedule determined by the MO HealthNet Division. Providers must bill their costs for the hearing aids. Reimbursement will not exceed the lesser of the maximum allowed amount determined by the MO HealthNet Division or the provider’s billed charge.
5. (10) Services/Items Provided in a Nursing Home. A request for audiological testing and a hearing aid must originate with the participant and must proceed with the participant’s full knowledge and consent. All hearing aids and related services performed or provided in a nursing home, boarding home, domiciliary home, or institution require prior authorization as specified in section (3), with the exception that audiological testing performed in these places of service also requires prior authorization.
6. (11) Binaural Hearing Aids. Binaural hearing aids may be covered by MO HealthNet if medically necessary and if prescribed by an otolaryngologist, otologist, or otorhinolaryngologist.
7. (12) Exception to Audiometric Criteria. If, despite speech discrimination less than forty percent (40%) or PTA threshold less than 30dB HL, there are special circumstances that would justify the need and benefit of a hearing aid, prior authorization may be granted.
8. (13) Replacement Hearing Aids. Prior authorization may be granted for a second hearing aid within four (4) years if the first hearing aid was lost, destroyed or ceased to function effectively and cannot be repaired.

9. (14) Hearing Aid Repairs. MO HealthNet will cover necessary repairs to any eligible participant’s hearing aid that is no longer under warranty. The warranty period on new aids or repairs will be for one (1) year from the date the hearing aid is dispensed. The methods of reimbursement for repairs are as follows:

   1. (A) Out-of-shop Repairs. Necessary repairs made out-of-shop, where the aid must be sent out to the manufacturer or repair lab, will be reimbursed at twenty dollars ($20) plus the invoiced cost of the repair. The twenty dollars ($20) covers the provider’s cost for postage and processing. Included also is any postage for returning the aid to the provider, any insurance fee charged and a six (6)- month warranty; and

   2. (B) In-shop Repairs. Necessary repairs made in-shop will be reimbursed at the provider’s cost for parts plus a reasonable charge for labor. The state consultant will determine the reasonable charge for labor. Repairs will be considered as in-shop repairs for—

      1. 1. Any repair made in the provider’s

office;

1. 2. Any repair made in a provider-owned

and/or operated repair or manufacturing lab; or

1. 3. Any repair made by a provider who is

employed by or affiliated with another provider who owns or operates a repair or manufacturing lab.

1. (15) Post-fitting Adjustments. A maximum of three (3) post-fitting adjustments or hearing aid repairs or any combination totaling three

2. (3) are covered in a twelve (12)-month period. Minor adjustments and repairs such as the following must be billed as a post-fitting adjustment:

   1. (A) Resetting or adjusting the frequency response of the aid;
   2. (B) Modifying an earmold;
   3. (C) Checking that the ear, earmold and tubing are not occluded with ear wax;
   4. (D) Removing of ear wax from the earmold and tubing;
   5. (E) Venting earmold or closing vent;
   6. (F) Adjusting maximum power output;
   7. (G) Reinstructing the patient in the use and care of the aid;
   8. (H) Performing minor in-shop hearing aid repairs;
   9. (I) Conducting hearing retests;
   10. (J) Evaluating the electroacoustic hearing aid; or
   11. (K) Cleaning the hearing aid.

3. (16) Basic Program Limitations. Benefits under the hearing aid program are limited by the following:

   1. (A) A participant is entitled to one (1) new hearing aid and related services (testing, earmold, fitting, dispensing, and post-fitting evaluation) per four (4) years;
   2. (B) Backup or spare hearing aids are noncovered regardless of when first hearing aid was dispensed;
   3. (C) Any hearing aid for the purpose of binaural amplification must be prescribed by an otolaryngologist, otologist or otorhinolaryngologist;
   4. (D) All repairs for hearing aids must include a six (6)-month warranty;
   5. (E) MO HealthNet will not reimburse for repairs to a hearing aid that is five (5) years of age or older; and
   6. (F) A new hearing aid will not be purchased within six (6) months of the repair of an old hearing aid.

AUTHORITY: sections 208.152, 208.153, and 208.201, RSMo Supp. 2007.* This rule was previously filed as 13 CSR 40-81.120. Emergency rule filed June 1, 1979, effective June 11, 1979, expired Sept. 13, 1979. Original rule filed June 1, 1979, effective Sept. 14, 1979. Emergency amendment filed April 10, 1981, effective April 20, 1981, expired July 10, 1981. Amended: Filed April 10, 1981, effective July 11, 1981. Rescinded and readopted: Filed July 18, 1989, effective March 1, 1990. Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 29, 2005, effective Jan. 30, 2006. Amended: Filed June 15, 2006, effective Dec. 30, 2006. Amended: Filed March 17, 2008, effective Oct. 30, 2008. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007; and 208.201, RSMo 1987, amended 2007.