CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Hearing Aid Mandate

Commercial products only; defines coverage limits, eligible items (external hearing aids) and excluded items/services under the Rhode Island hearing aid mandate. Prior authorization not required; policy applies to device coverage and billing codes.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Hearing Aid Mandate

Policy CodePolicy N/A

Change TypeClarified (administrative)

Effective DateJan 14, 2014

Next Review Date

Key ActionVerify member's Evidence of Coverage for applicable DME benefits and apply age-based hearing aid benefit limits and three-year replacement frequency when submitting claims.

SourceLink

POLICY UPDATE CHANGES

Policy last updated 09|03|2019; document states policy is current at time of publication.

2Age-based coverage tiers

3 yearsReplacement interval

MultipleCovered HCPCS device codes listed

MultipleNon-covered assistive device codes listed

Coverage Summary

This policy applies to Commercial products only and implements the Rhode Island statutory hearing aid mandate. It reflects state requirements for coverage of external hearing aids and the billing/coding approach for those devices.

The mandate defines an external hearing aid as: "any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, but excluding batteries, cords, and other assistive listening devices, including, but not limited to, FM systems."

Coverage includes age-based monetary limits: $1,500 per individual hearing aid, per ear, per occurrence for individuals under 19, and $700 per individual hearing aid, per ear, per occurrence for individuals 19 and older, with a replacement interval of every three (3) years per ear. Note that federal EHB rules for Qualified Health Plans (QHPs) may supersede state limits in certain situations.

For Commercial products under this policy, prior authorization review is not required.

Replacement intervalEvery three (3) years per ear

Coverage amount under age 19$1,500 per individual hearing aid, per ear, per occurrence

Coverage amount age 19 and older$700 per individual hearing aid, per ear, per occurrence

Coverage Eligibility and Prior Auth Rules

Coverage Eligibility and Limits

Coverage under the Hearing Aid Mandate is provided when the statutory conditions are met:

ALL of the following

Member is covered under Commercial products (policy is applicable to Commercial products only).
Definition of external hearing aid: Device is an external hearing aid as defined: 'any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, but excluding batteries, cords, and other assistive listening devices, including, but not limited to, FM systems.'
Coverage limits by age and frequency are met
- Age-based limits: For anyone under the age of nineteen (19) years: coverage up to $1,500 per individual hearing aid, per ear, per occurrence.$1,500 per ear per occurrence (age <19)
- Age-based limits: For anyone of the age of nineteen (19) years and older: coverage up to $700 per individual hearing aid, per ear, per occurrence.$700 per ear per occurrence (age ≥19)
- Replacement frequency: Statutory replacement frequency: every three (3) years (per ear).every three (3) years
Evidence of Coverage governs: Benefits may vary by group/contract; member's Evidence of Coverage / Benefit Booklet / Subscriber Agreement govern applicability and any differences.

Prior Authorization

Prior authorization requirements for Commercial products:

Prior authorization review is not required.

Non-covered Items and Services

Some items and services excluded from the hearing benefit (for example, batteries, assistive listening devices, certain dispensing/assistive codes) may instead be covered under the member's durable medical equipment (DME) benefit depending on the contract. Verify coverage in the member's Evidence of Coverage / Benefit Booklet / Subscriber Agreement for plan-specific applicability.

Coding Lists (HCPCS / CPT)

Covered HCPCS (hearing aid devices) - applies to DME benefit and counts toward hearing aid benefit maximumHCPCSCovered

V5030	Hearing aid, monaural, body worn, air conduction
V5040	Hearing aid, monaural, body worn, bone conduction
V5050	Hearing aid, monaural, in the ear
V5060	Hearing aid, monaural, behind the ear
V5070	Glasses, air conduction
V5080	Glasses, bone conduction
V5100	Hearing aid, bilateral, body worn
V5120	Binaural, body
V5130	Binaural, in the ear
V5140	Binaural, behind the ear

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1/5

DME Benefit / Covered under member's DME (but not part of mandate)HCPCSCovered

V5264	Ear mold/insert, not disposable, any type
V5265	Ear mold/insert, disposable, any type
V5275	Ear impression, each

Unlisted / Documentation required (unlisted code process)HCPCS

V5090	Dispensing fee, unspecified hearing aid
V5298	Hearing aid, not otherwise classified
V5299	Hearing service, miscellaneous

Not separately reimbursedHCPCSNot Covered

S0618

Audiometry for hearing aid evaluation to determine the level and degree of hearing loss (not separately reimbursed under this policy)

Non-covered (not part of hearing benefit/mandate)HCPCS|CPTNot Covered

V5266	Battery for use in hearing device
V5267	Hearing aid or assistive listening device/supplies/accessories, not otherwise specified
V5268	Assistive listening device, telephone amplifier, any type
V5269	Assistive listening device, alerting, any type
V5270	Assistive listening device, television amplifier, any type
V5271	Assistive listening device, television caption decoder
V5272	Assistive listening device, TDD
V5273	Assistive listening device, for use with cochlear implant
V5274	Assistive listening device, not otherwise specified
V5281	Assistive listening device, personal FM/DM system, monaural

1–10 of 34

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Provider Actions & Billing Rules

Prior Authorization

Prior authorization not required

No prior authorization review is required for hearing aid coverage under this policy for Commercial products.

Documentation Required

Use LT/RT modifiers for monaural codes

LT or RT modifiers must be used on monaural codes to identify the ear. Do not use LT/RT on bilateral/binaural codes.

Billing Rule

Benefit maximum application

Covered HCPCS hearing aid device codes bill to the member's DME benefit and apply toward the hearing aid benefit maximum by ear and occurrence when mandate guidelines are met.

Billing Rule

Unlisted codes require documentation

The following unlisted codes follow the unlisted code process and require documentation to be submitted.

V5090
V5298
V5299

Denial Risk

Non-covered items excluded from mandate

Claims for assistive listening devices, batteries, and certain listed CPT/HCPCS service codes are not covered as part of the hearing aid mandate and may be denied under the hearing benefit; these items may be covered under the member's DME benefit—verify the member's Evidence of Coverage.

Definitions & Background

Rhode Island statute §27-20-46 requires that health insurance contracts delivered or renewed in the state provide hearing aid coverage: $1,500 per individual hearing aid, per ear, every three (3) years for anyone under 19, and $700 per individual hearing aid, per ear, every three (3) years for anyone 19 and older. The policy implements this mandate and applies to Commercial products.

The statute and policy specify that a "hearing aid" means: "any nonexperimental, wearable instrument or device designed for the ear and offered for the purpose of aiding or compensating for impaired human hearing, but excluding batteries, cords, and other assistive listening devices, including, but not limited to, FM systems."

Hearing aids are included in the Rhode Island Benchmark Plan that defines Essential Health Benefits for RI QHPs; federal EHB rules for QHPs may supersede state mandates with respect to removing annual and lifetime dollar limits. The mandate also notes it is not typically necessary to replace a hearing aid more than once every three years.

Revision History

2019-09-03last_reviewLatest

Policy last updated 09/03/2019; no clinical policy statement changes announced; appears administrative update.

2014-01-14effective_date

Policy effective 01/14/2014 implementing Rhode Island hearing aid mandate and coverage limits.