Section 354.1231 - Benefits and Limitations(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.1 Tex. Admin. Code § 354.1231
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 beeffectiveJuly 4, 2010, 35 TexReg 5521; Amended to be effective October 17, 2012, 37 TexReg 8198; Amended by Texas Register, Volume 43, Number 46, November 16, 2018, TexReg 7517, eff. 11/20/2018