HMSA's plans cover hearing aids that are necessary to correct hearing loss. Such services are subject to plan deductibles and coinsurance percentages.
The following information applies to most of HMSA's plans except for the following coverage codes: 455, 532, 533, 558, 651, 669, and 673. For these coverage codes, please refer to the Hearing Aids - Non ACA Plans.
Effective as of January 1, 2014 HMSA will process hearing aids based on new established eligible charges that are based on the different types of models available. Benefits are available for medically appropriate hearing aid models (analog, digital, digitally programmable) with standard features. It is important that providers are aware that the difference between a participating provider's charge for the hearing aid and HMSA's eligible charge is considered a provider adjustment and not charged to the member. Hearing aids are not covered by the Children's Plan or by Medicare Advantage.
Member Upgrade Option for Completely in the Canal (CIC) Hearing Aid
Effective date of service July 1, 2015, Hearing Aid Suppliers can now offer members the option to purchase CIC hearing aid(s) that do not meet payment determination criteria by using the Acknowledgement of Financial Responsibility [PDF] (AFR) form. Once the member has signed the AFR form, claims may be submitted to HMSA using the upgrade billing criteria developed by the CMS, using modifier GA/GK. HMSA will make payment for the medically necessary hearing aid(s) and the member will be held liable for the difference in upgrade costs.
NOTE: Payment policy excludes Federal Plan 87 members and HMSA Plan for Postal Service Employees.
Non-Covered Services and Features
Members are responsible for separately charged costs related to nonstandard (cosmetic, convenience or advanced technology) features that include, but are not limited to:
- Replacement battery for use in hearing device
- Extended warranty
- Ear mold and/or insert
- Hearing aid accessories (i.e., dry and store kits)
- Dispensing fee
- Bluetooth accessories
- Automatic volume control (compression)
- Ear impressions
- Low-battery indicator
- Conformity evaluation
- Fitting, adjustment, orientation, and/or checking of a hearing aid
- Insurance against loss or damage
NOTE: Under HMSA benefit guidelines, hearing aids are limited to one hearing aid per ear every 60 months. Benefit payments for standard hearing aids are limited to no more than the eligible charge.
Coding Tips
- Modifier LT (left) or RT (right) are required when billing for monaural hearing aids.
- When billing for binaural hearing aids, modifier LT or RT is not required because binaural applies to both ears. The binaural hearing aids must be billed with a quantity of 1 unit.
- Charges for nonstandard features are entered on a separate line below the standard code. Charges for nonstandard features are billed with HCPCS code S1001 and the member will be held liable.
Billing Guidelines for Hearing Aid Repairs and Replacements
Effective 1/1/2022, precertification is required for hearing aid repairs and replacements. Please refer to the medical policy for Durable Medical Equipment, Prosthetics and Orthotics for more information.
- When billing for replacement hearing aids, modifier RA is required.
- Use HCPCS V5014 when billing for a repair.
- When submitting a precertification request for repairs, please include an invoice.
Billing Guidelines for CIC Upgraded Hearing Aids
The claim must be billed with two line items on the same claim. HMSA will not make partial payment on claims with upgraded CIC hearing aid(s) when the upgrade modifiers are not billed as indicated below or when not billed in the specified order.
| Line 1: | Bill the HCPCS code that describes the upgraded CIC hearing aid (HCPCS code V5242, V5244, V5248, V5250, V5254, V5258) that was actually dispensed to the member and append modifier GA. A properly obtained AFR waiver form must be signed by the member. |
| Line 2: | Bill the HCPCS code that describes the reasonable and necessary hearing aid that is medically necessary and covered by HMSA and append modifier GK. |
The claim line with modifier GA will be denied as not medically necessary with full patient responsibility. The claim line with the modifier GK will be processed based on the member's plan benefits with eligible charge, coinsurance and deductible applied as applicable.
Claim Example for CIC Upgraded Hearing Aid
The following example illustrates how to file claims for hearing aids when the member has elected to purchase a CIC hearing aid(s) and a properly obtained AFR form is obtained.
A patient is equipped with a digital monaural CIC hearing aid (V5254) for the right ear. The total charge is $3,900. Member has signed an AFR form that is kept in the member's file Claim lines would be submitted as followed:
| Standard Code | Code Description | Modifier | Modifier | Charges | HMSA Eligible | Provider Adjustment | HMSA Allowance | Member Owes |
|---|---|---|---|---|---|---|---|---|
| V5254 | Hearing aid, digital, monaural, CIC | GA | RT | $2,500 | $0.00 | $0.00 | $0.00 | $2,500 |
| V5255 | Hearing aid, digital, monaural, ITC | GK | RT | $1,400 | $1,400 | $0.00 | $1,040 | $360 |
Note that the CIC hearing aid charge ($2,500) represents the difference between the supplier's charge ($3,900) and the allowable charge amount for the covered standard hearing aid ($1,400).The member's plan benefit for a hearing aid is 80% of the eligible charge after a $100 deductible has been applied.
Claim Examples for Non-covered Services and Features
The following examples illustrate how to file claims for non-covered services and features. The provider may bill the patient for nonstandard features. In some cases, HMSA may request an itemization of all charges. To prevent misunderstandings, providers are urged to discuss the financial responsibility for the non-covered services with the member prior to dispensing the devices.
All figures in the examples below are rough estimates and for illustration purposes only.
Example 1
A patient is equipped with a standard digital, behind-the-ear (BTE) monaural hearing aid (V5257) for the right ear with ear mold (V5264). The provider submits a claim for the fitting, orientation and/or checking of hearing aid (V5011), the conformity evaluation (V5020), the hearing aid (V5257), the monaural dispensing fee (V5241), the battery for the hearing aid (V5266), the ear mold (V5264) and the ear mold impression (V5275). The charge for the hearing aid is $1,400. The patient's plan benefit for hearing aid(s) is 80% of the eligible charge after a $100 deductible has been applied.
| Standard Code | Code Description | Modifier | Charges | HMSA Eligible | Provider Adjustment | HMSA Allowance | Member Owes |
|---|---|---|---|---|---|---|---|
| V5011 | Fitting/orientation/checking of hearing aid | RT | $140 | $0.00 | $0.00 | $0.00 | $140 |
| V5020 | Conformity evaluation | RT | $75 | $0.00 | $0.00 | $0.00 | $75 |
| V5257 | Hearing aid, digital, monaural, BTE | RT | $1,400 | $1,200 | $200 | $880 | $320 |
| V5241 | Dispensing fee, monaural hearing aid, any type | RT | $180 | $0.00 | $0.00 | $0.00 | $180 |
| V5266 | Battery for use in hearing device | RT | $10 | $0.00 | $0.00 | $0.00 | $10 |
| V5264 | Ear mold/insert, not disposable, any type | RT | $65 | $0.00 | $0.00 | $0.00 | $65 |
| V5275 | Ear impression, each | RT | $50 | $0.00 | $0.00 | $0.00 | $50 |
Example 2
A patient is equipped with a standard digital, in-the-ear (ITE), binaural hearing aid (V5260) and wants a nonstandard Bluetooth accessory. The provider submits a claim for the fitting, orientation and/or checking of hearing aid (V5011), conformity evaluation (V5020), the hearing aid (V5260), the binaural dispensing fee (V5160), the battery for the hearing aids (V5266) and the nonstandard Bluetooth accessory (S1001). The charge for the binaural hearing aids are $2,800.The patient's plan benefit for hearing aids are covered at 50% of the eligible charge after a $100 deductible has been applied.
| Standard Code | Code Description | Modifier | Charges | HMSA Eligible | Provider Adjustment | HMSA Allowance | Member Owes |
|---|---|---|---|---|---|---|---|
| V5011 | Fitting/orientation/checking of hearing aid | LTRT | $140 | $0.00 | $0.00 | $0.00 | $140 |
| V5020 | Conformity evaluation | LTRT | $75 | $0.00 | $0.00 | $0.00 | $75 |
| V5260 | Hearing aid, digital, binaural, ITE | $2,800 | $2,600 | $200 | $1,250 | $1,350 | |
| V5160 | Dispensing fee, binaural hearing aid, any type | $180 | $0.00 | $0.00 | $0.00 | $180 | |
| V5266 | Battery for use in hearing device | LTRT | $10 | $0.00 | $0.00 | $0.00 | $10 |
| S1001 | Deluxe item, patient aware (list in addition to code for basic item) | LTRT | $450 | $0.00 | $0.00 | $0.00 | $450 |
Returns
If a newly dispensed hearing aid is returned by the member, any benefit payment made by HMSA for the hearing aid should be returned to HMSA.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |