907 KAR 1:039. Payments for hearing services.

 

      RELATES TO: KRS 205.520, 334.010, 334.040, 334.200, 334A.020(5), 42 C.F.R. 447.200, 204

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)

      NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services, has responsibility to administer the program of Medical Assistance. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the method for determining amounts payable by the department for hearing services.

 

      Section 1. Definitions. (1) "Audiologist" is defined by KRS 334A.020(5).

      (2) "Comparable instrument" means an instrument falling within the general classifications of fitting type, for example, body, behind-the-ear, in-the-ear, or eyeglasses.

      (3) "Department" means the Department for Medicaid Services.

      (4) "Hearing instrument" is defined by KRS 334.010(4).

      (5) "Specialist in hearing instruments" is defined by KRS 334.010(9).

 

      Section 2. Reimbursement to an Audiologist. The department shall reimburse a participating audiologist at usual and customary actual billed charges up to the fixed upper limit per procedure established by the department at sixty-five (65) percent of the median billed charge using 1989 calendar year billed charges.

 

      Section 3. Hearing Instrument Reimbursement. (1) If a manufacturer of a hearing instrument billed to the department submits a price schedule which includes the manufacturer’s invoice price of the hearing instrument, the department shall reimburse the participating specialist in hearing instruments at the lesser of:

      (a) The manufacturer’s invoice price plus a professional fee of:

      1. $150 for the first (one (1) ear) hearing instrument; and

      2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two (2) hearing instruments are dispensed on the same date;

      (b) The actual specialist in hearing instruments’ cost plus a professional fee of:

      1. $150 for the first (one (1) ear) hearing instrument; and

      2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two (2) hearing instruments are dispensed on the same date; or

      (c) The suggested retail price submitted by the manufacturer for the hearing instrument.

      (2) If a manufacturer of a hearing instrument billed to the department has not submitted a price schedule which includes the manufacturer’s invoice price for the hearing instrument, the department shall reimburse the participating specialist in hearing instruments at the lesser of:

      (a) The lowest price submitted for a comparable hearing instrument plus a professional fee of:

      1. $150 for the first (one (1) ear) hearing instrument; and

      2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two (2) hearing instruments are dispensed on the same date;

      (b) The actual specialist in hearing instruments’ cost plus a professional fee of:

      1. $150 for the first (one (1) ear) hearing instrument; and

      2. Fifty (50) dollars for the second (two (2) ears or binaural) hearing instrument if two (2) hearing instruments are dispensed on the same date; or

      (c) The lowest suggested retail price submitted by a manufacturer for a comparable instrument.

 

      Section 4. Replacement Cord Reimbursement. The department shall reimburse for a replacement cordat the specialist in hearing instruments’ cost plus a professional fee set at $21.50.

 

      Section 5. Hearing Instrument Repair Reimbursement. The department shall reimburse a specialist in hearing instruments for a hearing instrument repair:

      (1) On the basis of the manufacturer's charge for repair or replacement of parts;

      (2) Plus the specialist in hearing instruments’ cost for postage and insurance relative to the repair;

      (3) Plus a professional fee of $21.50; and

      (4) Not to exceed the price of a new hearing instrument.

 

      Section 6. Appeals. A provider may appeal a department decision as to the application of this administrative regulation in accordance with 907 KAR 1:671. (Recodified from 904 KAR 1:039, 5-2-86; Am. 17 Ky.R. 572; eff. 10-14-90; 25 Ky.R. 1255; 1661; eff. 1-19-99; 34 Ky.R. 1823; 2112; eff. 4-4-08.)