101 CMR, § 323.03

Current through Register 1538, January 3, 2025

Section 323.03 - 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. MassHealth 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. MassHealth 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.

Code	Description	Rate
92541	Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording	$52.21
92542	Positional nystagmus test, minimum of four positions, with recording	$53.86
92544	Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording	$43.19
92545	Oscillating tracking test, with recording	$39.30
92546	Sinusoidal vertical axis rotational testing	$81.48
92547	Use of vertical electrodes (List separately in addition to code for primary procedure)	$24.52

2.Audiologic Function Tests with Medical Diagnostic Evaluation.

Code	Description	Rate
92551	Screening test, pure tone, air only	$9.49
92552	Pure tone audiometry (threshold); air only	$18.37
92553	Pure tone audiometry (threshold); air and bone	$26.26
92555	Speech audiometry threshold	$15.05
92556	Speech audiometry threshold; with speech recognition	$22.20
92557	Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)	$49.51
92562	Loudness balance test, alternate binaural or monaural	$18.73
92563	Tone decay test	$16.17
92565	Stenger test, pure tone	$14.31
92567	Tympanometry (impedance testing)	$20.36
92568	Acoustic reflex testing, threshold	$14.26
92572	Staggered spondaic word test	$8.39
92576	Synthetic sentence identification test	$18.61
92577	Stenger test, speech	$23.91
92579	Visual reinforcement audiometry (VRA)	$29.59
92582	Conditioning play audiometry	$31.82
92583	Select picture audiometry	$33.04
92584	Electrocochleography	$84.33
92587	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	$56.57
92588	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	$79.19
92590	Hearing aid examination and selection; monaural	$24.23
92591	Hearing aid examination and selection; binaural	$35.94
92592	Hearing aid check; monaural	$15.19
92593	Hearing aid check; binaural	$30.38
92594	Electroacoustic evaluation for hearing aid; monaural	$41.64
92595	Electroacoustic evaluation for hearing aid; binaural	$83.32
92596	Ear protector attenuation measurements	$26.62
92650	Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis	$67.81
92651	Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report	$67.81
92652	Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report	$94.37
92653	Auditory evoked potentials; neurodiagnostic, with interpretation and report	$94.37
V5020	Conformity evaluation	$90.94

3.Evaluative and Therapeutic Services.

Code	Description	Rate
92517	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP)	I.C.
92518	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP)	I.C.
92519	Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP)	I.C.
92601	Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming	$143.78
92602	Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent reprogramming (do not report 92602 in addition to 92601)	$98.64
92603	Diagnostic analysis of cochlear implant, 7 years or older; with programming	$90.51
92604	Diagnostic analysis of cochlear implant, 7 years or older; subsequent reprogramming (do not report 92604 in addition to 92603)	$58.69
92620	Evaluation of central auditory function, with report; initial 60 minutes	$59.45
92621	Evaluation of central auditory function, with report; each additional 15 minutes (List separately in addition to code for primary procedure)	$14.87
92626	Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour	$59.45
92627	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)	$14.87
92700	Unlisted otorhinolaryngologic service or procedure	I.C.

4.Miscellaneous.

Code	Description	Rate
V5008	Hearing screening	$30.83
V5010	Assessment for hearing	$62.53

(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.

Code	Description	Rate
V5090	Dispensing fee, unspecified hearing aid	$331.26
V5110	Dispensing fee, bilateral	$662.73
V5160	Dispensing fee, binaural	$662.73
V5200	Dispensing fee, CROS contralateral, monaural	$662.73
V5240	Dispensing fee, contralateral routing system, binaural	$662.73
V5241	Dispensing fee, monaural hearing aid, any type	$331.26

2.Hearing Aid Purchases.

Code	Description	Rate
V5030	Hearing aid, monaural, body worn, air conduction	AAC
V5040	Hearing aid, monaural, body worn, bone conduction	AAC
V5050	Hearing aid, monaural, in the ear	AAC
V5060	Hearing aid, monaural, behind the ear	AAC
V5070	Glasses, air conduction	AAC
V5080	Glasses, bone conduction	AAC
V5095	Semi-implantable middle ear hearing prosthesis	AAC
V5100	Hearing aid, bilateral, body worn	AAC
V5120	Binaural, body	AAC
V5130	Binaural, in the ear	AAC
V5140	Binaural, behind the ear	AAC
V5150	Binaural, glasses	AAC
V5171	Hearing aid, contralateral routing device, monaural, in the ear (ITE)	I.C.
V5172	Hearing aid, contralateral routing device, monaural, in the canal (ITC)	I.C.
V5181	Hearing aid, contralateral routing device, monaural, behind the ear (BTE)	I.C.
V5190	Hearing aid, contralateral routing, monaural, glasses	AAC
V5211	Hearing aid, contralateral routing device, monaural, behind the ear (BTE)	I.C.
V5212	Hearing aid, contralateral routing system, binaural, ITE/ITC	I.C
V5213	Hearing aid, contralateral routing system, binaural, ITE/BTE	I.C.
V5214	Hearing aid, contralateral routing system, binaural, ITC/ITC	I.C.
V5215	Hearing aid, contralateral routing system, binaural, ITC/BTE	I.C.
V5221	Hearing aid, contralateral routing system, binaural, BTE/BTE	I.C.
V5230	Hearing aid, contralateral routing system, binaural, glasses	AAC
V5242	Hearing aid, analog, monaural, CIC (completely in the ear canal)	AAC
V5243	Hearing aid, analog, monaural, ITC (in the canal)	AAC
V5244	Hearing aid, digitally programmable analog, monaural, CIC	AAC
V5245	Hearing aid, digitally programmable analog, monaural, ITC	AAC
V5246	Hearing aid, digitally programmable analog, monaural, ITE (in the ear)	AAC
V5247	Hearing aid, digitally programmable analog, monaural, BTE (behind the ear)	AAC
V5248	Hearing aid, analog, binaural, CIC	AAC
V5249	Hearing aid, analog, binaural, ITC	AAC
V5250	Hearing aid, digitally programmable analog, binaural, CIC	AAC
V5251	Hearing aid, digitally programmable analog, binaural, ITC	AAC
V5252	Hearing aid, digitally programmable, binaural, ITE	AAC
V5253	Hearing aid, digitally programmable, binaural, BTE	AAC
V5254	Hearing aid, digital, monaural, CIC	AAC
V5255	Hearing aid, digital, monaural, ITC	AAC
V5256	Hearing aid, digital, monaural, ITE	AAC
V5257	Hearing aid, digital, monaural, BTE	AAC
V5258	Hearing aid, digital, binaural, CIC	AAC
V5259	Hearing aid, digital, binaural, ITC	AAC
V5260	Hearing aid, digital, binaural, ITE	AAC
V5261	Hearing aid, digital, binaural, BTE	AAC
V5262	Hearing aid, disposable, any type, monaural	AAC
V5263	Hearing aid, disposable, any type, binaural	AAC
V5298	Hearing aid, not otherwise classified	AAC

(c)Maximum Fees for Earmolds. Provider's adjusted acquisition cost (AAC), plus a dispensing fee as set forth below.

Code	Description	Rate
V5264	Ear mold/insert, not disposable, any type	AAC+ $15.74
V5265	Ear mold/insert, disposable, any type	AAC+ $15.74

(d)Maximum Fee for Ear Impressions.

Code	Description	Rate
V5275	Ear impression, each	$15.74

(e)Maximum Fees for Batteries.

Code	Description	Rate
V5266	Battery for use in hearing device	$1.67
L8621	Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each	AAC
L8622	Alkaline battery for use with cochlear implant device, any size, replacement, each	AAC
L8623	Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each	AAC
L8624	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).

Code	Description	Rate
L8691	Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each	$1,931.37
L8692	Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment	I.C.
L8693	Auditory osseointegrated device abutment, any length, replacement only	$1,700.57
L8694	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.

Code	Description	Rate
V5267	Hearing aid or assistive listening device/supplies/accessories, not otherwise specified	AAC+ 45%
V5274	Assistive listening device, not otherwise specified	AAC+ 45%

(h)Maximum Fee for Refitting Services.

Code	Description	Rate
V5011	Fitting/orientation/checking of hearing aid	$37.35

(i)Maximum Fee for Minor Repairs.

Code	Description	Rate
99499	Unlisted evaluation and management service	$5.38

(j)Maximum Fee for Major Repairs.

Code	Description	Rate
V5014	Repair/modification of a hearing aid	AAC+ 45%

(k)Maximum Fees for Cochlear Implant Services.

Code	Description	Rate
L7510MS	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) (I.C.) (for use only for the purchase of a cochlear implant service contract in accordance with 130 CMR 426.416: Reimbursable Services.)	I.C.
L8615	Headset/headpiece for use with cochlear implant device, replacement	$337.44
L8616	Microphone for use with cochlear implant device, replacement	$78.60
L8617	Transmitting coil for use with cochlear implant device, replacement	$68.65
L8618	Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement	$19.62
L8619	Cochlear implant, external speech processor and controller, integrated system, replacement	$7,259.54
L8627	Cochlear implant, external speech processor, component, replacement	$6,518.03
L8628	Cochlear implant, external controller component, replacement	$1,130.05
L8629	Transmitting coil and cable, integrated, for use with cochlear implant device, replacement	$163.56
L9900	Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code	I.C.

(l)Maximum Fee for Other Services.

Code	Description	Rate
V5299	Hearing service, miscellaneous	I.C.

(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.

101 CMR, § 323.03

Amended by Mass Register Issue 1336, eff. 4/7/2017.

Amended by Mass Register Issue 1449, eff. 8/6/2021.

Amended by Mass Register Issue 1508, eff. 11/1/2023.