Policy Title: Supplemental Hearing Aids Effective Period: 1/1/ /31/2019 Applies To: Generations Advantage All Plans
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1 Benefit Policy Policy Title: Supplemental Hearing Aids Effective Period: 1/1/ /31/2019 Applies To: Generations Advantage All Plans PURPOSE The Hearing Aids benefit provides coverage for hearing aids which are not covered by Original Medicare. This policy defines the Hearing Aids benefit. POLICY Coverage: The benefit includes coverage for the pre-approved economy-class hearing aids provided by Amplifon. Hearing aid fittings and evaluations are covered in conjunction with the hearing aid benefit at no cost to the member. The member is allowed one hearing aid per ear, each calendar year. Generations Advantage recognizes that some members may wish to purchase non-economy-class devices. In recognition of this, the member may choose non-economy hearing aids through Amplifon only, but Generations Advantage will only pay up to the non-economy allowance. The hearing aid and fitting may only be provided by an Amplifon network provider. Members who have received an audiogram within 6 months from a non-amplifon provider may provide the test to the Amplifon audiologist or will receive a new audiogram free of charge. Members who purchase hearing aids through Amplifon will receive a complimentary two-year supply of batteries up to a maximum of 160 cells per hearing aid. Economy Class: Economy-class hearing aids include six channels, fixed noise and feedback reduction, remote control connection, one non-automatic directional microphone, available in all styles. Members may contact Amplifon at (888) for any hearing aid device questions. Member Responsibility: A copay will be applied for each economy-class hearing aid purchased per ear. Copays will vary based on the economy class of hearing aid selected and the member s plan. Please see the Evidence of Coverage document for applicable copay. Should the member choose non-economy-class hearing aids, they will be subject to additional cost, see Non-Economy Allowance and Balance Billing.
2 Non-Economy Allowance: A non-economy allowance is a dollar limit allowed for hearing aids*. The non-economy allowance per ear is the following: Prime Plan Flex Plan Select Plan Value Plus Plan Focus DC Plan Value $100 $100 $100 $100 $100 $400 *Please note dollar allowance is non-transferrable, e.g. leftover funds on the right ear may not be applied to the left ear hearing aid. Balance Billing: Members will not be balance billed for services. However, should the member purchase a noneconomy device through Amplifon, the member will be responsible for the difference between the billed amount and the benefit maximum at the time of purchase. CLAIM SUBMISSIONS Claims for hearing aids will be submitted directly by Amplifon. If a non-economy hearing aid is chosen, Amplifon will indicate the cost difference for non-economy class hearing aids on a separate line with modifier GY. EXCLUSIONS The following items are excluded from coverage Non-Hearing-Aid Accessories Hearing Aids Provided by Vendors other than Amplifon Replacement for Lost or Stolen Devices Services or supplies provided by non-participating providers SOURCES (Regulatory and Accreditation) Medicare Managed Care Manual, Chapter 4 Evidence of Coverage Document
3 REVIEW AND REVISION DATES Approval Date: 12/10/2018 Revision Dates: 12/10/2018, 12/20/2018, 1/4/2018 Approved by the Health Plan Administration Department
4 Addendum A: Coding Policy Number: B107A Effective Period: 1/1/ /31/2019 Policy Title: Supplemental Hearing Aids Applies To: Generations Advantage All Plans Hearing Aids Monaural V5257 Hearing aid, digital, monaural, behind the ear V5256 Hearing aid, digital, monaural, in the ear V5255 Hearing aid, digital, monaural, in the canal V5254 Hearing aid, digital, monaural, completely in canal Hearing Aids Binaural (bilateral) V5261 Hearing aid, digital, binaural, behind the ear V5260 Hearing aid, digital, binaural, in the ear V5259 Hearing aid, digital, binaural, in the canal V5258 Hearing aid, digital, binaural, completely in canal V5267 Hearing aid or assistive listening device/supplies/accessories, not otherwise specified Hearing Aids, Contralateral routing of signal (CROS) and bilateral microphones with contralateral routing of signal (BICROS) V5171 Hearing aid, contralateral routing device, monaural, in the ear (ite) V5172 Hearing aid, contralateral routing device, monaural, in the canal (itc) V5181 Hearing aid, contralateral routing device, monaural, behind the ear (bte) V5211 Hearing aid, contralateral routing system, binaural, ite/ite V5212 Hearing aid, contralateral routing system, binaural, ite/itc V5213 Hearing aid, contralateral routing system, binaural, ite/bte V5214 Hearing aid, contralateral routing system, binaural, itc/itc V5215 Hearing aid, contralateral routing system, binaural, itc/bte V5221 Hearing aid, contralateral routing system, binaural, bte/bte
5 Addendum B: Tiers Policy Title: Supplemental Hearing Aids Effective Period: 1/1/ /31/2019 Applies To: Generations Advantage All Plans TIER 1 TIER 1 PRODUCT DESCRIPTION REXTON JOY 10 BTE JOY 10 M BTE JOY 10 P BTE JOY 10 S BTE STERLING 10 ITE STERLING 10 HS STERLING 10 ITC STERLING 10 CIC STERLING 10 E1 CIC STERLING 10 E1 ITC STERLING 10 E1 HS STERLING 10 E1 ITE MOSAIC 10 E1 S BTE MOSAIC 10 E1 P BTE MOSAIC 10 E1 M BTE MOSAIC 10 E1 HP BTE
6 TIER 2 OTICON PRODUCT DESCRIPTION GET LP ITE P GET LP ITE GET HS P GET HS GET ITC P GET ITC GET MIC P GET MIC GET CIC P GET CIC GET BTE GET P BTE UNITRON PRODUCT DESCRIPTION T INSERA A IIC OMNI T INSERA A CIC OMNI T INSERA 500 W 10A CIC OM T INSERA 500 W 10A MC D T INSERA 500 W 13 ITE D T INSERA ITC OMNI T INSERA HS OMNI T INSERA 500 W 312 ITC D T INSERA 500 W 312 HS D STRIDE 500 W 13 ITE D STRIDE 500 W 312 HS D STRIDE 500 W 312 ITC D STRIDE 500 W 10A MC D STRIDE A CIC OMNI STRIDE A IIC STRIDE 500 W 10A CIC OMNI STRIDE M 500 BTE STRIDE P 500 BTE STRIDE P DURA 500 BTE T MOXI NOW 500 RIC BTE T MOXI KISS 500 RIC BTE T MOXI FIT 500 RIC BTE T MOXI DURA 500 RIC BTE T MOXI FIT 500 R RIC BTE T STRIDE M 500 BTE
7 T STRIDE P DURA 500 BTE T STRIDE P 500 BTE T MOXI ALL 500 RIC BTE TIER 3 MIRACLE EAR OTICON PRODUCT DESCRIPTION AUDIOTONE PRO 3S BTE AUDIOTONE PRO 3P BTE AUDIOTONE PRO 3SP BTE AUDIOTONE PRO 3 ITE AUDIOTONE PRO 3 HS AUDIOTONE PRO 3 ITC AUDIOTONE PRO 3 CIC PRODUCT DESCRIPTION DYNAMO SP4 BTE HIT LP ITE HIT HS HIT CANAL HIT MIC P HIT MIC HIT CIC HIT CIC P HIT RITE BTE HIT MINI BTE HIT BTE HIT BTE P HIT PRO LP ITE HIT PRO HS HIT PRO CANAL HIT PRO MIC HIT PRO MIC P HIT PRO CIC HIT PRO CIC P HIT PRO RITE BTE HIT PRO BTE P HIT PRO MINI BTE HIT PRO BTE INO LP ITE P INO LP ITE INO HS
8 INO HS P INO CANAL INO CANAL P INO MIC INO MIC P INO CIC INO CIC P INO RITE BTE INO MINIRITE BTE INO MINI BTE INO BTE P INO BTE RIA BTE RIA CIC RIA CIC P RIA ITE RIA ITE P RIA HS RIA HS P RIA ITC RIA ITC P RIA MINI BTE RIA MINIRITE BTE RIA P BTE RIA RITE BTE RIA2 ITE RIA2 ITE P RIA2 HS P RIA2 HS RIA2 ITC P RIA2 ITC P RIA2 ITC RIA2 CIC RIA2 CIC P RIA2 MINIRITE BTE RIA2 RITE BTE RIA2 BTE P RIA2 MINI BTE RIA2 BTE RIA2 PLUS BTE P
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