SECTION 355.8141. Reimbursement for Hearing Aid Services

(a) The Texas Department of Health or its designee shall make direct vendor payments to providers of hearing aid services participating in the Texas Medical Assistance (Medicaid) Program. Participating providers are reimbursed within the limits defined by the maximum allowable fee schedule for hearing aid services established by the Texas Board of Health.

(b) Reimbursement for a hearing aid shall be based on the lowest of the invoice cost of the hearing aid, the acquisition cost of the hearing aid, or the department's maximum allowable fee.

(1) Providers must include on the claim form the model number, serial number, and warranty date of the hearing aid.

(2) The department may authorize reimbursement for a hearing aid that exceeds the maximum allowable fee under the following conditions:

(A) the recipient shall certify in writing a preference for a specific hearing aid; and

(B) the recipient shall acknowledge in the certification the responsibility to pay the difference between the acquisition cost of the preferred instrument and the department's maximum allowable fee.

(3) The department or its designee shall establish a fee schedule to set the upper limits of reimbursement for authorized hearing aid services. The fee schedule shall include costs for hearing aids, earmolds, evaluation, fitting and dispensing, and follow-up visits.

(A) The maximum allowable fee schedule is subject to periodic review by the department or its designee to determine if adjustment to the fee schedule is necessary. The fee schedule is compared to the aggregate of providers' billed charges and invoice or acquisition costs to determine the necessity for and extent of adjustment. Any adjustment to the fee schedule is subject to the availability of legislatively appropriated funds. The department or its designee informs participating providers of changes to the fee schedule through the Texas Medicaid Bulletin which is distributed to all providers enrolled in the Texas Medicaid Program.

(B) Reimbursement for a physician's examination to determine the need for a hearing aid shall not be subject to the fee schedule. The department shall consider the examination a physician service and shall reimburse physicians according to the methodology described in §29.1104 of this title (relating to Texas Medicaid Reimbursement Methodology (TMRM)).

(4) The department or its designee does not reimburse institutions or hospitals for hearing aid services and supplies as separate items of service if these supplies and services are included in their reimbursement formula.

Source Note: The provisions of this §355.8141 adopted to be effective February 14, 1985, 10 TexReg 406; amended to be effective September 1, 1986, 11 TexReg 3648; amended to be effective July 1, 1992, 17 TexReg 3913; 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; duplicated effective September 1, 1997, as published in the Texas Register December 11, 1998, 23 TexReg 12660