PROVIDER-SPECIFIC POLICIES

PROVIDERS ELIGIBLE TO PARTICIPATE

All hearing aid dispensers and audiologists licensed in Iowa are eligible to participate in the Medicaid program. Audiologist in other states must be qualified by having a Certificate of Clinical Competence in Audiology granted by the American Speech-Language-Hearing Association or by having successfully completed a minimum of 350 clock-hours of supervised clinical practicum and successfully completed a nationally approved examination in audiology. Submit requests for participation to the Iowa Medicaid Enterprise (IME).

PROCEDURE FOR A MEMBER TO OBTAIN A HEARING AID

The steps in the process for a Medicaid member to obtain a hearing aid are: 

♦ Physician examination 

♦ Audiological evaluation 

♦ Hearing evaluation 

♦ Hearing aid selection 

♦ Purchase of hearing aid

1. Physician Examination

Members who believe themselves to be in need of a hearing aid, or who are advised of a possible need, should begin by contacting their primary care physician for an examination to determine whether there is any condition that would contraindicate the use of a hearing aid. An examination by an otologist or otolaryngologist is preferred.

EXCEPTION: A physical examination may be waived if the member is 18 years of age or older and has signed an informed consent statement acknowledging that:

 ♦ The member has been advised that it may be in the member’s best health interest to receive a medical evaluation from a licensed physician before purchasing a hearing aid, and 

 ♦ The member does not wish to receive a medical evaluation before the purchase.

A physician examination or waiver does not need to be repeated for replacement hearing aids, unless Medicaid payment for hearing aids was not previously made.

2. Audiologic Evaluation

A physician or an audiologist must perform pure-tone and speech audiometry to evaluate the member’s hearing sensitivity. 

Due to various factors, such as age and cognitive ability to understand and respond, pure-tone air conduction, bone conduction, and speech audiometry may not be applicable to all members. If alternative audiological evaluations are employed, written documentation or support reports should be included in the member’s record.

3. Hearing Evaluation

The hearing aid evaluation is performed to determine whether the member may benefit from the use of amplification. The evaluation procedures should be standard and appropriate as a means of determining the type of hearing aid and amplification characteristics needed for the member’s condition.

Hearing aid evaluation and selection codes 92590 and 92591 are payable only when provided by audiologists.

4. Hearing Aid Selection

A physician or audiologist may recommend a specific brand or model appropriate to the member’s condition. “Appropriate” shall mean adequate for the member’s condition and a reasonable expenditure as well. Reasonableness is determined by whether:

♦ The expense of the hearing aid would be clearly disproportionate to the therapeutic benefits which the member could derive from it;

♦ The hearing aid would be substantially more costly than an appropriate and realistically feasible alternative brand or model; or 

♦ The hearing aid serves essentially the same purpose as an item already available to the member.

When a physician or audiologist makes a general hearing aid recommendation, a hearing aid dispenser may perform tests to determine the specific brand or model appropriate to the member’s condition. Hearing aid selection, code V5010, is payable only to hearing aid dispensers.

A hearing aid selection fee is not allowed for replacement of hearing aids that are lost, broken beyond repair or stolen and the replacement aid is like for like.

5. Purchase of Hearing Aid

The member may obtain the hearing aid from the enrolled provider of the member’s choice who can provide the hearing aid recommended.