N.J. Admin. Code § 10:64-1.5

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:64-1.5 - Basis of reimbursement

(a) Reimbursement for a new hearing aid shall be the lower of the following charges:

1. The provider's usual and customary charges; or

2. A charge consisting of the following:

i. Wholesale cost of the instrument; plus

ii. Wholesale cost of the earmold, as per laboratory invoice or laboratory price list; plus

iii. Insurance, shipping, and handling costs included as a component of the manufacturer's cost; plus

iv. Wholesale cost of the batteries; plus

v. A dispensing fee of $ 175.00 for a monaural fitting or $ 280.00 for a binaural fitting.

(b) Reimbursement for a returned hearing aid shall be as follows:

1. Should it be determined at the follow-up examination that the prescribed hearing aid properly supplied has failed to provide the beneficiary with the anticipated communication benefit, and that a different aid will not be prescribed (that is, there will be no exchange), the provider shall be reimbursed for services and materials upon return of the hearing aid, at the lower of the following:

i. The provider's usual and customary charge; or

ii. A charge consisting of the following:

(1) Wholesale cost of the earmold, as per laboratory invoice or laboratory price list; plus

(2) Wholesale cost of the batteries, cord and garment bag, as per laboratory invoice or laboratory price list; plus

(3) The manufacturer's restocking fee, if any; plus

(4) A service fee of $ 30.00.

(c) Replacement of an aid within one year from date of original dispensing, if not covered by the manufacturer's warranty, shall be reimbursed at the lower of the following:

1. The provider's usual and customary charge; or

2. A charge consisting of the following:

i. Wholesale cost of the instrument; plus

ii. Wholesale cost of the earmold, as per laboratory invoice or laboratory price list; plus

iii. Insurance, shipping, and handling costs included as a component of the manufacturer's cost; plus

iv. A dispensing fee of $ 50.00.

(d) Reimbursement for repair of a hearing aid, if not covered by the manufacturer's warranty, shall be the lower of the following:

1. The provider's usual and customary charge; or

2. A charge consisting of the following:

i. Manufacturer's cost of repair; plus

ii. A 50 percent service fee.

(e) Reimbursement for replacement parts, if not covered by the manufacturer's warranty, shall be the lower of the following:

1. The provider's usual and customary charge; or

2. A charge consisting of the following, depending upon the part or parts to be replaced:

i. Earmolds: Wholesale cost, as per laboratory invoice or laboratory price list, plus $ 10.00;

ii. Batteries, which shall be provided as a three month's supply: Manufacturer's list price less 20 percent;

iii. Cords: Manufacturer's list price less 20 percent;

iv. Receivers: Manufacturer's list price less 20 percent;

v. Garment bags: Manufacturer's list price less 20 percent.

(f) In addition to other remedies provided under State and Federal laws, rules and regulations, the Department of Medical Assistance and Health Services may deny payments and/or recoup payments from a provider if:

1. The recipient of a hearing aid did not meet the hearing aid candidacy requirements at N.J.A.C. 10:64-2.1(b);

2. Documentation submitted by the provider does not justify dispensing a hearing aid; or

3. The provider did not comply with the procedures for dispensing a hearing aid in accordance with N.J.A.C. 10:49 and this chapter.

N.J. Admin. Code § 10:64-1.5

Amended by R.2001 d.71, effective 3/5/2001.
See: 32 New Jersey Register 3965(a), 33 New Jersey Register 793(a).
In (b)1, substituted "beneficiary" for "recipient".
Amended by R.2006 d.289, effective 8/21/2006.
See: 38 New Jersey Register 1385(a), 38 New Jersey Register 3304(a).
In (b)1, substituted "provider" for "dispenser"; and added (f).