General Rate Provisions, Requirements, and Rates

(1) General Rate Provisions. Payment for the purchase of hearing aids and authorized related accessories and services for the care and maintenance of hearing aid instruments are the lowest of (a) the provider's usual charge to persons other than publicly aided individuals and industrial accident patients; (b) the provider's actual charge submitted; or (c) the schedule or maximum fees listed in 101 CMR 323.03(5). (2) Reimbursement as Full Payment. The payment rates under 101 CMR 323.03 are full compensation for care rendered to publicly aided individuals and industrial accident patients, as well as for any related administrative or supervisory duties and costs in connection with the services provided. Each provider must, as a condition of acceptance of payment made by the governmental unit purchasing audiological services or purchaser under M.G.L. c. 152 (the Workers’ Compensation Act), accept the rate as full payment and discharge of all obligations for the services rendered. (3) General Requirements and Services Included. (a) Purchase of Hearing Aids. Payment for a hearing aid includes 1. the hearing aid and standard accessories for the proper operation of the hearing aid and proper fitting and instruction in the use, care, and maintenance of the hearing aid; and minor repairs and services as usually provided non–publicly aided individuals and industrial accident patients that may be necessary during the operational life of the hearing aid; 2. a mandatory one-year manufacturer's warranty and/or insurance against loss or damage; and 3. the cost of a loaner hearing aid when necessary. (b) Earmold. Payment for an earmold includes the proper fitting of the earmold on delivery, and adjustments as may be needed. The maximum fee stipulated in 101 CMR 323.03(5)(c) is not allowed if an earmold is included in the manufacturer's price of the aid or the client already has an earmold. (c) Ear Impression. Payment for an ear impression includes one properly formed ear impression for each in-the-ear (ITE), in-the-canal (ITC), and behind-the-ear (BTE) aid purchased. The fee stipulated in 101 CMR 323.03(5)(d) is allowed only at the time an aid is purchased. The fee listed in 101 CMR 323.03(5)(d) includes provision for all associated costs. (d) Batteries. Proper freshness of batteries must be ensured. The maximum fee listed in 101 CMR 323.03(5)(e) includes provision for all associated costs. Batteries must be new and unused at the time of purchase. (e) Other Accessories or Options for a Hearing Aid. Proper fitting and adjustment of the accessory must be provided as needed. The maximum fee listed in 101 CMR 323.03(5)(g) includes provision for all associated costs. Accessories must be new and unused at the time of purchase. (f) Refitting Services/Other Professional Services. Additional fitting/refitting services are reimbursed only if the hearing aid was dispensed more than one year prior to the date of service of the refitting services. These professional services include refitting of the aid, orientation, counseling the member or member’s family, contact with interpreters, fitting of a loaner aid, and similar services. Reimbursement for such services must include a face-to-face encounter with the publicly aided individual or industrial accident patient. (g) Minor Repairs and Office Visits for Evaluation and Management Services. An office visit for evaluation and management services is reimbursed only when one or more of the following services is required and is provided as part of the visit: 1. minor adjustments to the hearing aid to ensure a proper fitting, such as an earmold adjustment, when a provider is not the provider who initially fit the hearing aid, and the provider who initially fit the hearing aid no longer provides services to publicly aided individuals or industrial accident patients; 2. minor office repairs for which the provider customarily charges patients who are neither publicly aided individuals nor industrial accident patients; 3. cleaning of the hearing aid; or 4. replacement of parts such as, but not limited to, tubing, hooks, battery doors, and replacement. No fee is allowed when the provider does not customarily charge clients other than publicly aided individuals and industrial accident patients for these repairs. (h) Major Repairs. A provider may submit a bill for major repairs to a hearing aid only after all warranties and/or insurance have expired. The hearing aid in need of a major repair must be sent directly to the repair facility or manufacturer that will perform the repair. Handling charges by an intermediary may not be submitted. Repair services must include a written warranty against all defects for a minimum of six months unless otherwise documented by the repair facility or manufacturer. The provider of the repair services is responsible for the quality of the workmanship and parts, and for ensuring that the repaired aid is in proper working condition. The maximum fee listed in 101 CMR 323.03(5)(j) includes provision for all associated costs. (i) Extended Insurance Covering Loss and Damage. The manufacturer's insurance policy must provide coverage for the loss or damage of a hearing aid for no less than one year and up to three years following purchase. (j) Other Services. No payment is allowed when the provider does not customarily charge clients other than publicly aided individuals and industrial accident patients for such items. (4) Two Audiologists. The MassHealth agency pays for two audiologists working together to perform an evaluation of an individual member when the knowledge, skills, and experience of the primary audiologist have identified a need for a second audiologist to aid in completing the initial test battery, such as for the testing of very young children or those with other pertinent developmental, physical, cognitive, or maturational factors. Circumstances warranting the services of two audiologists must be fully documented in the member’s medical record. To receive full payment, both audiologists must use the appropriate service code and modifier combination listed in Subchapter 6 of the MassHealth Audiologist Manual. The MassHealth agency will pay 1/2 of the total allowable payment for two audiologists to each individual provider. (5) Rates. 101 CMR 323.03(5) sets forth maximum fees for the items and services listed in 101 CMR 323.03(5). (a) Maximum Fees for Audiological Services. 1. Vestibular Function Tests, with Recording and Medical Diagnostic Evaluation. Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Positional nystagmus test, minimum of four positions, with recording Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Oscillating tracking test, with recording Sinusoidal vertical axis rotational testing Use of vertical electrodes (List separately in addition to code for primary procedure) 2. Audiologic Function Tests with Medical Diagnostic Evaluation. Screening test, pure tone, air only Pure tone audiometry (threshold); air only Pure tone audiometry (threshold); air and bone Speech audiometry threshold Speech audiometry threshold; with speech recognition Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) Loudness balance test, alternate binaural or monaural Tone decay test Stenger test, pure tone Tympanometry (impedance testing) Acoustic reflex testing, threshold Staggered spondaic word test Synthetic sentence identification test Stenger test, speech Visual reinforcement audiometry (VRA) Conditioning play audiometry Select picture audiometry Electrocochleography Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report Hearing aid examination and selection; monaural Hearing aid examination and selection; binaural Hearing aid check; monaural Hearing aid check; binaural Electroacoustic evaluation for hearing aid; monaural Electroacoustic evaluation for hearing aid; binaural Ear protector attenuation measurements Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report Auditory evoked potentials; neurodiagnostic, with interpretation and report Conformity evaluation 3. Evaluative and Therapeutic Services. Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) IC Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP) IC Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP) IC Diagnostic analysis of cochlear implant, patient younger than 7 years old; with programming Diagnostic analysis of cochlear implant, patient younger than 7 years old; subsequent reprogramming (do not report 92602 in addition to 92601) Diagnostic analysis of cochlear implant, 7 years of age or older; with programming Diagnostic analysis of cochlear implant, 7 years of age or older; subsequent reprogramming (do not report 92604 in addition to 92603) Evaluation of central auditory function, with report; initial 60 minutes Evaluation of central auditory function, with report; each additional 15 minutes (List separately in addition to code for primary procedure) Diagnostic analysis, programming, and verification of an auditory osseointegrated sound processor, any type; first 60 minutes Diagnostic analysis, programming, and verification of an auditory osseointegrated sound processor, any type; each additional 15 minutes Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List separately in addition to code for primary procedure) Unlisted otorhinolaryngologic service or procedure IC 4. Miscellaneous. Hearing screening Assessment for hearing (b) Maximum Fees for Hearing Aids. The maximum fees are the adjusted acquisition cost (AAC) of the hearing aid, plus the appropriate dispensing fee. 1. Hearing Aid Dispensing Fees. Dispensing fee, unspecified hearing aid Dispensing fee, bilateral Dispensing fee, binaural Dispensing fee, CROS contralateral, monaural Dispensing fee, contralateral routing system, binaural Dispensing fee, monaural hearing aid, any type 2. Hearing Aid Purchases. Hearing aid, monaural, body worn, air conduction AAC Hearing aid, monaural, body worn, bone conduction AAC Hearing aid, monaural, in the ear AAC Hearing aid, monaural, behind the ear AAC Glasses, air conduction AAC Glasses, bone conduction AAC Semi-implantable middle ear hearing prosthesis AAC Hearing aid, bilateral, body worn AAC Binaural, body AAC Binaural, in the ear AAC Binaural, behind the ear AAC Binaural, glasses AAC Hearing aid, contralateral routing device, monaural, in the ear (ITE) IC Hearing aid, contralateral routing device, monaural, in the canal (ITC) IC Hearing aid, contralateral routing device, monaural, behind the ear (BTE) IC Hearing aid, contralateral routing, monaural, glasses AAC Hearing aid, contralateral routing device, monaural, behind the ear (BTE) IC Hearing aid, contralateral routing system, binaural, ITE/ITC IC Hearing aid, contralateral routing system, binaural, ITE/BTE IC Hearing aid, contralateral routing system, binaural, ITC/ITC IC Hearing aid, contralateral routing system, binaural, ITC/BTE IC Hearing aid, contralateral routing system, binaural, BTE/BTE IC Hearing aid, contralateral routing system, binaural, glasses AAC Hearing aid, analog, monaural, CIC (completely in the ear canal) AAC Hearing aid, analog, monaural, ITC (in the canal) AAC Hearing aid, digitally programmable analog, monaural, CIC AAC Hearing aid, digitally programmable analog, monaural, ITC AAC Hearing aid, digitally programmable analog, monaural, ITE (in the ear) AAC Hearing aid, digitally programmable analog, monaural, BTE (behind the ear) AAC Hearing aid, analog, binaural, CIC AAC Hearing aid, analog, binaural, ITC AAC Hearing aid, digitally programmable analog, binaural, CIC AAC Hearing aid, digitally programmable analog, binaural, ITC AAC Hearing aid, digitally programmable, binaural, ITE AAC Hearing aid, digitally programmable, binaural, BTE AAC Hearing aid, digital, monaural, CIC AAC Hearing aid, digital, monaural, ITC AAC Hearing aid, digital, monaural, ITE AAC Hearing aid, digital, monaural, BTE AAC Hearing aid, digital, binaural, CIC AAC Hearing aid, digital, binaural, ITC AAC Hearing aid, digital, binaural, ITE AAC Hearing aid, digital, binaural, BTE AAC Hearing aid, disposable, any type, monaural AAC Hearing aid, disposable, any type, binaural AAC Hearing aid, not otherwise classified AAC (c) Maximum Fees for Earmolds. Provider's adjusted acquisition cost (AAC), plus a dispensing fee as set forth in 130 CMR 323.03(5)(c). Ear mold/insert, not disposable, any type AAC+ $15.74 Ear mold/insert, disposable, any type AAC+ $15.74 (d) Maximum Fee for Ear Impressions. Ear impression, each (e) Maximum Fees for Batteries. Battery for use in hearing device Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each AAC Alkaline battery for use with cochlear implant device, any size, replacement, each AAC Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each AAC Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each AAC (f) Maximum Fees for Bone-anchored Hearing Aids (BAHA). Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each $1,931.37 Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment IC Auditory osseointegrated device abutment, any length, replacement only $1,700.57 Auditory osseointegrated device, transducer/actuator, replacement only, each $1,059.11 (g) Maximum Fees for Other Accessories. Provider's adjusted acquisition cost (AAC), plus a 45% markup. Hearing aid or assistive listening device/supplies/accessories, not otherwise specified AAC+ 45% Assistive listening device, not otherwise specified AAC+ 45% (h) Maximum Fee for Refitting Services. Fitting/orientation/checking of hearing aid (i) Maximum Fee for Minor Repairs. Unlisted evaluation and management service (j) Maximum Fee for Major Repairs. Repair/modification of a hearing aid AAC+ 45% (k) Maximum Fees for Cochlear Implant Services. L7510-MS Repair of prosthetic device, repair or replace minor parts (six-month maintenance and servicing fee for reasonable and necessary parts and labor that are not covered under any manufacturer or supplier warranty) (IC) (for use only for the purchase of a cochlear implant service contract in accordance with 130 CMR 426.416: Reimbursable Services.) IC Headset/headpiece for use with cochlear implant device, replacement Microphone for use with cochlear implant device, replacement Transmitting coil for use with cochlear implant device, replacement Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement Cochlear implant, external speech processor and controller, integrated system, replacement $7,259.54 Cochlear implant, external speech processor, component, replacement $6,518.03 Cochlear implant, external controller component, replacement $1,130.05 Transmitting coil and cable, integrated, for use with cochlear implant device, replacement Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code IC (l) Maximum Fee for Other Services. Hearing service, miscellaneous IC (6) Medical Services. The payment rates for medical services are set forth in 101 CMR 317.00: Rates for Medicine Services. (7) Therapeutic Services. The payment rates for therapeutic services are set forth in 101 CMR 339.00: Rates for Restorative Services.