Medicaid Handbook Transmittal Letter (MHTL) No. 3344-05-03

September 22, 2005

TO:  All Eligible Providers of Durable Medical Equipment, including
all Eligible Providers of Hearing Aid Services
Directors, County Department of Job and Family Services
Medical Assistance Coordinators

FROM:       Barbara E. Riley, Director

SUBJECT:       OAC rules 5101:3-10-11 Hearing Aids, 5101:3-10-25 Lactation Pumps, 5101:3-1-60Medicaid reimbursement and 5101:3-10-20 Covered orthotic and prosthetic services and associated limitations

The purpose of this Medicaid Handbook Transmittal Letter is to provide notice that the previous OAC rule 5101:3-10-11 Hearing Aids has been rescinded and replaced by a new version of the rule effective September 1, 2005 and creation of a new OAC rule 5101:3-10-25 Lactation Pumps effective September 1, 2005. OAC rules 5101:3-1-60 Medicaid reimbursement and 5101: 3-10-20 Covered orthotic and prosthetic services and associated limitations have been updated in conjunction with the expanded hearing aid coverage noted in rule 5101:3-10-11.

OAC Rule 5101:3-10-11  Hearing Aids

The medicaid rule pertaining to Hearing Aids (OAC 5101:3-10-11) requires prior authorization for all hearing aids to be covered and reimbursed. This rule also provides coverage for digital and programmable hearing aids for consumers 20 years or younger providing the medical necessity of the requested hearing aid is established. Consumers 21 years or older are eligible for conventional hearing aids only.

Other modifications to this rule include updated standardized hearing evaluations for consumers 20 years or younger as well as the authorization for the billing of a separate dispensing fee by providers fitting a hearing aid for medicaid consumers, effective for dates of service of September 1, 2005 and after. Hearing aid claims and submissions for equipment dispensed after September1, 2005 will require two separate HCPCS codes for full reimbursement. One HCPCS code will reimburse for the actual hearing aid being dispensed and one HCPCS code will reimburse for the professional services of the provider dispensing the hearing aid.

Dispensing fee codes as referenced in this rule and specific hearing aid codes must be submitted together on the same prior authorization request and if approved, must be billed together with the same date of service. ODJFS will pay for only one hearing aid and only one dispensing fee per consumer in a four-year period for a conventional hearing aid or only one hearing aid and one dispensing fee in a five year period for a programmable or digital hearing aid.

Providers with existing prior authorizations for hearing aids dispensed prior to September 1, 2005 must submit the code contained on the prior authorization approval letter and will be reimbursed at the current "all inclusive" rate. Providers with existing prior authorizations for hearing aids not dispensed until after September 1, 2005 may resubmit their existing prior authorization forms utilizing the new "separate fee" method consisting of one HCPCS code for the actual hearing aid and one HCPCS code for the dispensing of the hearing aid if they so desire. Providers resubmitting previously approved prior authorizations must note on their resubmission request that the submission has been previously authorized, and that authorization of the new hearing aid codes are being sought. It is recommended that providers include their original prior authorization document with their resubmission in order to facilitate this process.

OAC Rule 5101:3-1-60  Medicaid reimbursement

This rule contains the reimbursement provisions for the medicaid fee for service program. This rule was modified to include the addition of current HCPCS codes as well as updating coverage and pricing methodology for various existing codes within the appendix of this rule. These modifications included but were not limited to the adjustment of various codes in response to a ninternal audit conducted in order to verify that no existing medicaid codes were presently reimbursing at a higher rate than medicare. The majority of new HCPCS codes which were added to this filing of 5101:3-1-60 are being established as "non covered" codes in order to establish these codes in the Medicaid reimbursement system so that these codes are available for possible use in future versions of this rule. The effective date for this filling of 5101: 3-1-60 is September1, 2005.

In conjunction with the aforementioned change of OAC rule 5101: 3-10-11 Hearing Aids, the following codes are being activated and/or modified in order for providers to utilize them for dispense dates after September 1, 2005 in accordance with the previously mentioned instructions regarding reimbursement for Hearing aids:

Click here to reveal this information.

OAC Rule 5101: 3-10-20 Covered orthotic and prosthetic services and associated limitations

This rule contains the reimbursement provisions such as maximum units allowable and a comprehensive listing of covered devices within the appendix of this rule pertaining to the orthotic and prosthetic fee for service program. The changes in this rule are primarily the addition of HCPCS codes which would cover the addition of digital and programmable hearing aid for children as well as the removal of non covered HCPCS codes from this document. This rule will be effective September 1, 2005.

DME Question Line and Mailbox

In February 2005, the department established a DME Question Line and Mail box to improve response to provider questions regarding program coverage and limitations. The number for this service is 614-466-1503. The DME Question Line and Mailbox is not able to answer questions regarding individual consumer eligibility, PA requests or claims submissions. For these types of questions, providers should utilize the Interactive Voice Response (IVR) system or call Provider network management at 1-800-686-1516.

JFS 03142, rev. 02/2003- Prior Authorization Form

The department recommends that providers view this form and the entire text of the DME rules in the Durable Medical Equipment handbook at:      http://emanuals.odjfs.state.oh.us/emanuals

Click the link "Ohio Health Plan Providers" (left column) and then the link "Durable Medical Equipment" (right column).

Form JFS 03142 and other department forms can also be accessed at:

http://www.odjfs.state.oh.us/forms/inter.asp

If you do not have internet access, you may request a paper copy of this MHTL including all attachments by completing and returning the attached form JFS 03400.

Questions pertaining to this MHTL should be addressed to:

Bureau of Plan Operations
Provider Network Management Section
P.O. Box 1461
Columbus, Ohio 43216-1461
Toll free telephone number 1-800-686-1516

Attachment

Click here to view the JFS 03400, Health Plan Provider Update Request Form for MHTL 3344-05-03.

JFS 03142 - Prior Authorization

Click here to view the Prior Authorization .