| (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.
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| Source Note: The provisions of this §354.1231 adopted to be effective February 14, 1985, 10 TexReg 406; amended to be effective September 1, 1986, 11 TexReg 3648; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective September 3, 1996, 21 TexReg 7986; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective September 1, 2003 28 TexReg 7288; amended to be effective October 1, 2005, 30 TexReg 6042; amended to be effective December 2, 2008, 33 TexReg 9667; amended to be effectiveJuly 4, 2010, 35 TexReg 5521; amended to be effective October 17, 2012, 37 TexReg 8198; amended to be effective November 20, 2018, 43 TexReg 7517 |
