Mont. Admin. r. 37.86.805

Current through Register Vol. 23, December 6, 2024

Rule 37.86.805 - HEARING AID SERVICES, REIMBURSEMENT

(1) The department will pay the lowest of the following for covered hearing aid services and items:

(a) the provider's reasonable usual and customary charge for the service or item;

(b) the amount specified for the particular service or item in the department's fee schedule. The department adopts and incorporates by reference the department's Hearing Aid Fee Schedule as provided in ARM 37.85.105(3)(c); or

(c) 100% of the Medicare Region D allowable fee.

(2) For items or services where no Medicare allowable fee is available, the fee schedule amount in (1)(b) will be calculated using the following methodology:

(a) Establishing a fee for a service that has been billed at least 50 times by all providers in the aggregate during the previous 12-month period. The department will set each fee at the payment-to-charge ratio under ARM 37.85.105(2)(e).

(b) For supplies or equipment, reimbursement will be set at 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount. For items that are custom-fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

(c) For services where utilization cannot meet the methodology outlined in (a), the fee will be set at the same rate as a service similar in scope.

(3) The provider may bill Medicaid for a dispensing fee, as specified in the fee schedule adopted in (1)(b). The dispensing fee covers and includes the initial ordering, fitting, orientation, counseling, two return visits for the services listed, and the insurance for loss or damages covered under a one-year warranty.

Mont. Admin. r. 37.86.805

NEW, 1980 MAR p. 973, Eff. 3/14/80; AMD, 1981 MAR p. 559, Eff. 6/12/81; AMD, 1981 MAR p. 1975, Eff. 1/1/82; AMD, 1982 MAR p. 1289, Eff. 7/1/82; AMD, 1988 MAR p. 596, Eff. 3/25/88; AMD, 1989 MAR p. 859, Eff. 6/30/89; AMD, 1990 MAR p. 1326, Eff. 7/13/90; AMD, 1998 MAR p. 2168, Eff. 8/14/98; AMD, 1999 MAR p. 1379, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2002 MAR p. 1779, Eff. 6/28/02; AMD, 2003 MAR p. 1314, Eff. 7/1/03; AMD, 2005 MAR p. 385, Eff. 3/18/05; AMD, 2007 MAR p. 1824, Eff. 11/9/07; AMD, 2008 MAR p. 1156, Eff. 7/1/08; AMD, 2009 MAR p. 2029, Eff. 10/30/09; AMD, 2009 MAR p. 2485, Eff. 1/1/10; AMD, 2010 MAR p. 1533, Eff. 7/1/10; AMD, 2011 MAR p. 1384, Eff. 7/29/11; AMD, 2011 MAR p. 2825, Eff. 1/1/12; AMD, 2012 MAR p. 2494, Eff. 1/1/13; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2014 MAR p. 1405, Eff. 7/1/14; AMD, 2017 MAR p. 2287, Eff. 12/9/2017; AMD, 2018 MAR p. 1734, Eff. 8/25/2018; AMD, 2018 MAR p. 2057, Eff. 10/20/2018; AMD, 2024 MAR p. 2024, Eff. 8/10/2024

AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-113, MCA