Section 140.417 Limitations on Optometric Services

Section 140

TITLE 89: SOCIAL SERVICES

CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES

SUBCHAPTER d: MEDICAL PROGRAMS

PART 140 MEDICAL PAYMENT

SECTION 140.417 LIMITATIONS ON OPTOMETRIC SERVICES

Section 140.417  Limitations

on Optometric Services

Payment for the following

optometric services and materials shall be made subject to the following

limitations:

a)         Payment shall be made for single vision lenses only when the

following conditions are met:

1)         The power is at least 0.75 diopters in either the sphere or

cylinder component; or

2)         The difference between the old and new prescription is at

least 0.75 diopters in either the sphere or cylinder component.

b)         Payment shall be made for bifocal lenses only when the

following conditions are met:

1)         For

first bifocals, the power of the bifocal addition is at least 1.00 diopter.

2)         For a change in bifocal lenses, the power of the bifocal

addition is changed by at least 0.50 diopters or the distance power represents

a change of at least 0.75 diopters.

c)         Payment shall be made for more than one examination per year

only when the vendor documents the need for the additional examination.

d)         Effective July 1, 2012, payment shall be made for the

following:

1)         One pair of eyeglasses or set of lenses for adults in a

24-month period.  Effective August 18, 2017, adults 21 years of age and older

may receive an additional pair of eyeglasses or set of lenses within the

24-month period if the patient has had a surgical procedure that necessitates a

new pair

examination.

d)         Effective July 1, 2012, payment shall be made for the

following:

1)         One pair of eyeglasses or set of lenses for adults in a

24-month period.  Effective August 18, 2017, adults 21 years of age and older

may receive an additional pair of eyeglasses or set of lenses within the

24-month period if the patient has had a surgical procedure that necessitates a

new pair.

2)         Payment shall be made for more than one pair of eyeglasses or

set of lenses per year for children through age 20 only when the physician or

optometrist documents:

A)        that:

i)          the most recent pair of eyeglasses or set of lenses was lost

or destroyed for reasons beyond the control of the recipient; or

ii)         there is a change in the prescription that meets the

requirements in subsection (a)(2) or (b)(2); and

B)        that the additional pair is medically necessary.

e)         Payment for optometric materials dispensed by a supplier other

than a physician or optometrist, except for replacement and repair items, shall

be made only when they are prescribed by a licensed physician or optometrist.

f)         Effective July 1, 2012, prior approval pursuant to Section

140.40 is required for the services and materials described in this subsection

(f).  Approval shall be given when, in the judgment of a Department consultant,

the requested item or service is appropriate.

1)         Contact lenses and related contact lens services;

2)         Custom made artificial eyes;

3)         Low vision devices;

4)         Any item or service not specifically included in the schedule

of procedures for optical services and supplies; and

5)         An a

dditional pair of eyeglasses or set of lenses within a

24-month period for adults

21 years of age and older

after eye surgery.