In New York, Medicaid provides payment for audiology and hearing air services to eligible patients when the need has been deemed medically necessary, and the use of hearing aids will diminish the patient’s disability that has been caused by the loss or impairment of their hearing.
Hearing aids and hearing loss treatment challenges many patients financially and the process involved in obtaining Medicaid coverage requires an attention to detail. Many states do not provide hearing aid coverage, but New York is an exception to this rule. Patients who follow the proper guidelines as set forth by the New York Medicaid program can obtain coverage for a hearing aid if they are truly in need.
Patients should seek out doctors or audiologists who fulfill the necessary Medicaid requirements in New York State and obtain all the written documents necessary to prove that they have a need for hearing aids.
Elderly patients will need to obtain written statements including:
● A written statement by a physician referring the patient to a qualified audiologist or otolaryngologist that has been kept with the patient record
● Written documentation of the audiometry results (or an equivalent test) or a prescription that has been signed by a licensed otolaryngologist or qualified audiologist
● After a trial period, the patient must obtain a written statement by an audiologist, the primary care provider, or the patient themselves that provides verification of benefit from the use of the hearing aid.
● If the patient fails to provide written verification of benefit, a written explanation by the dispenser of the hearing aid may be provided instead to support billing and to ensure that it has been included in the client record.
● A signed statement of rights and obligations must be provided to the patient by the dispenser of the hearing aids at the time the hearing aid is dispensed to the patient. A copy of this statement must be kept in the patient record. This statement must explain that the “trial period” is defined as the 30 days following dispensation of the hearing aid.
Once a Medicaid patient receives a hearing aid, they must return directly to the dispenser for calibrations or adjustments of the device during the initial 45-day trial period. Written confirmation of benefit to the patient (as mentioned above) is essential and if the hearing aid does not significantly benefit hearing or health, the patient is obligated to return it to the dispenser.
The New York Medicaid program provides payment for the following under certain conditions:
● Audiometric screening
● Audiology services
○ Hearing aid testing and evaluation
○ Conformity evaluation
○ Audiometric exams and testing
○ Hearing aid prescriptions and recommendations, as necessary
● Hearing aid services
○ Selection of a hearing aid
○ Hearing aid fitting
○ Dispensation of the hearing aid
○ Check-ups to confirm that the hearing aid is functioning properly
○ Hearing aid repairs
The Medicaid program requires that patients provide a written recommendation for hearing aids from either an otolaryngologist or an audiologist. An otolaryngologist is a licenced medical doctor who is either board certified or at least qualified to seek admission to exams provided by the American Board of Otolaryngology.
These doctors are often colloquially called Ear, Nose, and Throat specialists or ENT’s and they specialize in working with health problems that affect the ears, larynx, pharynx, or nose.
Patients may also receive coverage for hearing aids through a qualified audiologist. In order to participate in the Medicaid program, the audiologist must be registered to practice audiology by the New York State Education Department.
Residents of New York who seek treatment out of state, must find an audiologist who is qualified to practice audiology by a licensing agency in that state that’s equivalent to the licensing agency in New York state.
The hearing aid prescribed by the doctor or audiologist must conform to certain requirements that have been outlined by the state of New York. Hearing aid repairs and the replacement of accessories are also covered under certain conditions in order to keep the hearing aid functional.
In order to be eligible for reimbursement for hearing aid costs, Medicaid-eligible patients have to comply fully with Article 37 of the NYS General Business Law.
Who needs hearing aids?
Technically speaking, “normal” hearing is defined as the absence of hearing loss. But if you’re trying to get coverage for hearing aids, you’ll have to follow Medicaid’s guidelines to obtain coverage. Age-related hearing loss is a problem that affects a significant number of older adults in the U.S. Though hearing loss has been associated with an increased risk or various other negative health outcomes, coverage by Medicaid is not mandated by the federal government. Each state has to decide whether hearing aids are covered by Medicaid or not as well as the criteria that determines who is covered for these devices.
Medicaid determines who needs hearing aids using several different criteria including the following:
● Medical clearance
● Psychosocial evaluation that includes documentation that the patient is able to use and care for hearing aids and whether the patient receives assistance from a caregiver.
● History of hearing aid use including information about the year, make, and model of the hearing aid, the serial number, the ear that wore the hearing aid, the status of the hearing aid(s).
● Audiogram dated within the preceding 12 months of the hearing aid order date including air conduction information for both ears, bone conduction, and speech discrimination outcomes from the evaluation.
● If the hearing aid was lost, the patient or the patient’s caregiver must provide a letter that explains the circumstances surrounding the loss and how future loss will be prevented.
● Monaural hearing aid requests must indicate which ear will wear the device.
● Binaural device requests must include supporting documentation to support the patient’s qualification for binaural hearing aids.
● Hearing aids that are less than 5 years old must include an explanation with the request for coverage that explains why the patient needs a replacement rather than a repair.
New York state is one of only 28 states that provide coverage for hearing aids in the United States, but Medicaid has defined who qualifies for hearing aid coverage and who does not. Patients must provide the proper documentation when requesting approval for coverage for a hearing aid. Form eMedNY 283201 must be completed to obtain approval unless a request is submitted online by the patient through ePACES or some other HIPAA-compliant 278 transaction.
Does Medicaid pay for hearing aids for the elderly?
Elderly individuals who are eligible for Medicaid must be in compliance with Article 37 of the New York State General Business Law to receive reimbursements for their hearing aid costs. Elderly individuals must get a written recommendation for a hearing aid from either one of two types of hearing specialists:
● An Ear, Nose, and Throat Doctor (ENT), also known as an otolaryngologist or
● An audiologist
The recommendation must include the results of clinical audiometry pure tone and speech results that were obtained in a sound-treated room or a test suite that conforms to the American National Standard Institute’s requirements and specifications. The hearing specialist may write either a general recommendation that the patient receive a hearing aid or they may prescribe a specific type of hearing aid by indicating that the patient needs a particular model made by a specific manufacturer.
To get a prescription for a specific hearing aid that is covered by Medicaid, an elderly individual must receive a sound field speech audiometry test or an equivalent test that demonstrates a need. The test must be performed directly by an otolaryngologist or a licenced audiologist or under the personal direction of one of these professionals.
If a specific device is prescribed, the dealer of that device must provide the exact model to the patient that was prescribed by the doctor or audiologist. If a general recommendation for a hearing aid was made, the dealer of the hearing aid may measure the patient’s hearing using an audiometer or other types of testing equipment that’s used solely to select, fit, and dispense devices that are designed to improve hearing. Elderly individuals who are prescribed hearing aids must get their prescription filled within six months from the date the prescription was written to receive reimbursement from Medicaid.
What is Monaural Hearing Aid?
The word “monaural” refers to sound reception in one ear only. A patient with “monaural hearing loss” has hearing loss in just one ear. A monaural hearing aid is a device that’s worn in just one ear to correct a patient’s hearing. Monaural hearing aids were once the standard. Indeed, as recently as 1984, about 78% of all patients who had hearing aids had monaural fittings. Some recent studies have shown that patients with monaural fittings experienced hearing loss in the ear that was not wearing a hearing aid. This is called the Monaural Hearing Aid Effect. But while some studies support the use of binaural hearing aids even for monaural hearing loss, other studies have shown that patients with hearing loss in both ears experience no statistically significant difference in terms of their hearing quality whether they use monaural or binaural hearing aids to correct the problem.
The patient’s otolaryngologist or audiologist will likely recommend the best hearing aid(s) that will conform to the necessary specifications to guarantee coverage by Medicaid in New York. Patients must then decide whether the prescribed hearing aid provides substantial hearing and health benefits or not.
What are Binaural Hearing Aids?
The word “binaural” refers to sound reception in two ears. Over the past two decades, the use of binaural hearing aids has become standard practice. In other words, many ear, nose, and throat doctors and audiologists today recommend the use of two hearing aids to correct hearing loss even if the patient only has hearing loss in one ear. The goal of binaural hearing aid treatment is to replicate the normal binaural hearing that patients would have if they had no hearing loss in either of their ears.
Patients who have hearing loss in both ears have “binaural hearing loss”. Doctors will often recommend that patients who have experienced hearing loss in both of their ears should wear two hearing aids, but there is some debate over whether this is truly beneficial or not. It seems logical to assume that binaural hearing loss should be corrected with binaural hearing aids, but some patients prefer to get just one hearing aid to correct hearing in the ear that has the worst hearing and studies have shown that this strategy can be scientifically supported. In some cases, if patients don’t correct hearing in both ears, they may have trouble locating sounds and the sound quality of conversations may be very uneven. But some patients may find that binaural hearing aids do not provide significant benefit, particularly in social situations where there is a lot of background noise. These studies have shown that the FM system is the only successful binaural amplification strategy. Unfortunately, however, the FM system is not covered by Medicaid in New York state.
Approval Process for a Hearing Aid From Medicaid
Getting approved for a hearing aid starts with a prescription from a qualified medical provider for the device. The prescription may specify an exact model or it may be a general recommendation for a hearing aid. The entity (person, association, partnership, organization, or corporation) must be formally registered according to the provisions set forth in Article 37 of the General Business Law as a hearing aid dealer with the New York Department of State in order to dispense a hearing aid that will be covered by Medicaid. These entities may dispense hearing aids to individuals covered by Medicaid so long as the device adheres to the Hearing Aid/Audiology Services Fee Schedule.
Not-for-profit entities may also provide hearing aids through the New York Medicaid Program. These programs must employ a licensed otolaryngologist or be certified as a speech and hearing center that either provides services under the PHCP or as an Article 28 Facility that can participate in the Medicaid program under Title XVIII of the Social Security Act (Medicare).
Before making an application for hearing aid coverage, the Medicaid applicant must comply with certain specific standards that are found in the Official Codes, Rules, and Regulations of the Department of State. Hearing aid dealers must also comply with these regulations or they risk having their certificate of registration revoked along with their right to participate in the Medicaid program in New York.
When the cost of a hearing aid is not included with a non-profit facility’s rate, hearing aid reimbursement is made at the lower price that’s charged by the facility or at the cost of acquisition. And reimbursement for accessories such as earmolds or batteries are made at the lowest price charged by the facility, at the cost of acquisition by the facility, or according to the amount set forth by the State Maximum Fee Schedule.
To make a claim for coverage of a hearing aid, you must first obtain the device. Patients will do a trial period (30 days) to try the hearing aid and determine whether it will work for them or not. If during this trial period, the patient decides that they don’t want the hearing aid, the Medicaid claim will be voided when the hearing aid is returned. If an audiologist performs a check-up and confirms that the hearing aid is not benefiting the patient, payment for both the hearing aid and the dispensing fee will be forfeited.
If hearing benefits can’t be confirmed by an audiologist because the patient doesn’t return the hearing aid to the dispenser, the dispensation fee will be forfeited. However, if the dispenser is able to provide evidence through documentation that there has been a continuity of service with the patient, then the acquisition cost may still be reimbursable. If the patient loses their Medicaid eligibility before the hearing aid is dispensed, but after the hearing aid or earmold is ordered, Medicaid will only reimburse the patient for the earmold(s).
To receive reimbursement, the patient must submit the following to the appropriate Medicaid office:
● A copy of the invoice for the hearing aid must include the following information:
○ Brand name
○ Model number
○ Serial number
The patient may receive reimbursement for a hearing aid evaluation or checkup to confirm that the device is benefiting the patient. However, to receive reimbursement for these tests, the audiologist must not also be the dispenser of the hearing aid. In other words, there must not be a conflict of interest wherein the audiologist could benefit from confirming that a particular hearing aid device has improved the patient’s hearing. If the audiologist is also the hearing aid dispenser, they will not be eligible to receive a dispensing fee.
What kind of hearing aids does Medicaid cover?
Medicaid covers the following services related to the acquisition and maintenance of hearing aids for eligible patients:
● Hearing aids
● Hearing exams
● Ear molds
● Replacements
● Repairs
Patients should be aware of the following Medicaid coverage limitations that are determined by the extent of hearing loss in the ear that hears the best. Below are limitations that apply in situations when a patient needs a monaural hearing aid (a device for one ear that works individually as opposed to the use of two hearing aid devices with one placed in each ear):
● Hearing loss in the patient’s better ear must be 30 decibels or greater.
● Hearing loss for the pure tone average for the better ear must be 500, 1000, and 2000 Hz.
● A spondee threshold (intensity with which speech is recognized and understood by the patient) in the better ear must be 30 decibels or greater if the pure tone threshold can’t be determined.
● Hearing loss in each ear should be less than 30 decibels at frequencies less than 2000 Hz and at thresholds in each ear that are greater than 40 decibels at higher than 2000 Hz.
● Patients must have a documented need for the hearing aid.
● Patients must have a written statement that establishes that they are alert, oriented, and capable of using their hearing aid properly.
Reimbursement for a monaural hearing aid is the same regardless of the dispensing source.
Hearing aids were initially developed to work as individual units. A person with hearing loss in one ear would get a hearing aid just for that ear (known as a monaural hearing aid). In the early years of hearing aid development, a person with hearing loss in both ears would get two monaural hearing aids to correct the impairment. Today, monaural hearing aids are less common. Many patients today are prescribed binaural hearing aids.
Patients who need binaural hearing aids (two hearing aids that work in tandem to correct hearing loss) must fulfill the same criteria as patients who need monaural hearing aids in addition to at least one of the following criteria:
● The patient has significant educational, vocational, or social demands necessitating the use of binaural hearing aids.
● The patient has already used binaural hearing aids at some time in the past.
● The patient has a significant visual impairment.
● The patient is a child.
Note that FM Systems cannot be reimbursed by Medicaid in New York State.
Is Miracle Ear covered by Medicaid?
Miracle-Ear is an established direct-to-consumer hearing aid brand and it is not covered by Medicaid or Medicare. The brand was developed in 1948 by Dahlberg Electronics, but today it is owned by Amplifon in Plymouth, Minnesota. Today, all Miracle-Ear products are digitally based. The company has worked hard to develop a proprietary system through which speech is isolated from other sounds. It also features some valuable smartphone app functions to make mobile phone conversation easier.
Miracle-Ear companies provide hearing tests, fittings, and services that make them friendly to consumers. The average cost of a Miracle-Ear hearing aid averages between $1000 and $5000. Medicaid patients who wish to purchase a Miracle-Ear can apply to the Miracle-Ear Foundation for a free hearing aid. This foundation supplies free hearing aids to both children and adults who lack the financial means, government support, or insurance to acquire a suitable hearing aid to correct their hearing loss.
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