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Summary of CMS Medicaid Final Rule for Audiologists Payment Ties State Licensure to CCC-A or Medicare Standard

The Centers for Medicare and Medicaid Services (CMS) has released its final rule addressing Medicaid provider qualifications for audiologists in the May 28 issue of the Federal Register. The new CMS regulations mirror ASHA's positions and become effective June 28, 2004.

A chart summarizing these changes and the CMS final rule (in PDF format) are available on the ASHA Web site at:

In brief, the final rule:

  • Recognizes audiology as a separate profession;

  • Sets state licensure requirements, for Medicaid payment, to meet or exceed Certificate of Clinical Competence in Audiology (CCC-A);

  • Replaces the "or equivalent" with the Medicare standards (1993 CCC-A requirements); and

  • Requires supervision by audiologists for Medicaid audiology services performed by lesser qualified providers.

Payment Requirements

  • To qualify for Medicaid payment, the new regulations will require that state audiologist licensure standards meet or exceed the CCC-A or the Medicare statutory standards (that are the 1993 CCC-A requirements).

  • CMS clarified its policy further by saying, "We do not believe recognition of State licensure as the sole national standard for defining qualified audiologists is in the best interests of the Medicaid population."

  • The new regulation eliminates the "or equivalent educational requirements and work experience" clause, replacing it with the Medicare standards. The new regulation addresses complaints by audiologists that lesser qualified providers were directly billing Medicaid for audiology services, since 'equivalent' was widely interpreted by some states.

  • Audiologists are required to document that they have the CCC-A or meet the Medicare standard in states that:
    - Do not have licensure;
    - Have lesser licensure standards than CCC-A or Medicare standard; or
    - Exempt audiologists from licensure by institution or setting (such as schools).

  • CMS also stated, "Our revised standards continue recognition of ASHA certification, not only because it is a recognized industry quality standard, but more importantly because it ensures continuity and reciprocity..." and would "limit the administrative burden to States."

  • CMS also noted that American Board of Audiology certification would not be cited as a qualifying standard.

"Under the Direction of" Guidance"

CMS agreed with ASHA's comments to the proposed rule on the need to further strengthen its guidance on what constitutes providing audiology services "under the direction of" a qualified audiologist.

  • Audiology services provided under § 440.110(c)(1) require that the ''services be provided by or under the direction of an audiologist for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law.''

  • A federally qualified audiologist who is directing audiology services must supervise each beneficiary's care.

  • The qualified audiologist must see the beneficiary at the beginning of and periodically during treatment.

  • The supervising audiologist must assume professional responsibility for the services provided under his or her direction and monitor the need for continued services. The concept of professional responsibility implicitly supports face-to-face contact by the qualified audiologist at least at the beginning of treatment and periodically thereafter. Thus, audiologists must spend as much time as necessary directly supervising services to ensure beneficiaries are receiving services in a safe and efficient manner in accordance with accepted standards of practice.

  • To ensure the availability of adequate supervisory direction, supervising audiologists must ensure that individuals working under their direction have contact information to permit them direct contact with the supervising audiologist as necessary during the course of treatment.

  • The terms of the qualified audiologist's employment must ensure that the audiologist is adequately supervising any individual providing audiology services.

  • These employment terms should provide for supervisory ratios that are reasonable and ethical and in keeping with professional practice acts in order to permit the supervising audiologist to adequately fulfill his or her supervisory obligations and ensure quality care.

  • In all cases, documentation must be kept supporting the qualified audiologist's supervision of services and ongoing involvement in the treatment services. Because Medicaid law requires that documentation be kept supporting the provision and proper claiming of services, appropriate documentation of services provided by supervising audiologists, as well as services performed by individuals working under the direction of a qualified audiologist, are necessary.

  • Where appropriate, audiology services must adhere to all State requirements and State practice acts governing the provision of services under the direction of a qualified audiologist.

  • As with all Medicaid benefits that permit services furnished under direction, both Federal and State requirements must be met at the time services are furnished for the Medicaid program to appropriately provide Federal financial participation for services furnished on behalf of Medicaid eligible individuals.