Plain Text Law

Regulation .05 Limitations.

Regulation .05 Limitations.Copy Citation

A.
Covered audiology services, including hearing aids, cochlear implants, and auditory osseointegrated devices are limited to:
(1)
Unless the time limitation is waived by the Program, one audiology assessment per year;
(2)
The initial coverage of unilateral or bilateral hearing aids, cochlear implants, or auditory osseointegrated devices when the Department’s medical necessity criteria have been met;
(3)
One replacement of unilateral or bilateral hearing aids:
(a)
Every 5 years for participants younger than 21 years old, unless the Program approves more frequent replacement; or
(b)
Every 5 years for participants 21 years old or older, unless the Program approves more frequent replacement, but no more than 1 replacement extraneous to the devices’ warranty;
(4)
Replacement of hearing aids, cochlear implants and auditory osseointegrated device components that have been lost, stolen, or damaged beyond repair, after all warranties have expired;
(5)
Repairs and replacements that take place after all warranties have expired;
(6)
A maximum of 76 batteries per participant per 12-month period for a unilateral hearing aid or osseointegrated devices, or 152 batteries per participant per 12-month period for bilateral hearing aids or osseointegrated devices purchased from the Department not more frequently than every 6 months, and in quantities of 38 or fewer for a unilateral hearing aid, or 76 or fewer for a bilateral hearing aid;
(7)
A maximum of 238 disposable batteries for a unilateral cochlear implant per participant per 12-month period or 476 disposable batteries per 12-month period for a bilateral cochlear implant purchased not more frequently than every 6 months, and in quantities of 119 or fewer for a unilateral cochlear implant, or 238 or fewer for a bilateral cochlear implant;
(8)
Four replacement cochlear implant component rechargeable batteries per 12-month period for bilateral cochlear implants, and a maximum of two replacement rechargeable batteries for a unilateral cochlear implant per 12-month period;
(9)
Two cochlear implant replacement transmitter cables per 12-month period for bilateral cochlear implants, and a maximum of one replacement transmitter cable for a unilateral cochlear implant per 12-month period;
(10)
Two cochlear implant replacement headset cables per 12-month period for bilateral cochlear implants, and a maximum of one replacement headset cable for a unilateral cochlear implant per 12-month period;
(11)
Two replacement cochlear implant transmitting coils per 12-month period for bilateral cochlear implants, and a maximum of one replacement transmitting coil for a unilateral cochlear implant per 12-month period;
(12)
Charges for routine follow-ups and adjustments which occur more than 60 days after the dispensing of a new hearing aid; and
(13)
A maximum of two unilateral earmolds or four bilateral earmolds per 12-month period unless a larger number is determined to be medically necessary.
B.
Services which are not covered are:
(1)
Services not medically necessary;
(2)
Hearing aids and accessories not medically necessary;
(3)
Cochlear implant services and external components not medically necessary;
(4)
Cochlear implant services and external components provided less than 90 days after the surgery which are covered through the initial reimbursement;
(5)
Spare or backup cochlear implant components;
(6)
Spare or back-up auditory osseointegrated device components;
(7)
Replacement of hearing aids, equipment, cochlear implant components, and auditory osseointegrated device components if the existing devices are functional, repairable, and appropriately correct or ameliorate the problem or condition;
(8)
Spare or backup hearing aids, equipment, or supplies;
(9)
Repairs to spare or backup hearing aids, cochlear implants, auditory osseointegrated devices, equipment, or supplies;
(10)
Investigational or experimental services or devices, or both;
(11)
Replacement of improperly fitted earmold or earmolds unless the:
(a)
Replacement service is administered by someone other than the original provider; and
(b)
Replacement service has not been claimed before;
(12)
Additional professional fees and overhead charges for a new hearing aid when a dispensing fee claim has been made to the Program; and
(13)
Loaner hearing aids.