Current through Register Vol. 43, No. 02, November 27, 2024
(1) Authorization
(a) Recipients under 21 years of age are
authorized two pair of glasses each year if indicated by an examination; a
prior authorization will be required for subsequent pairs requested in a
calendar year. Recipients 21 years of age and older are authorized one pair of
eyeglasses every two calendar years if indicated by an examination; a prior
authorization will be required for subsequent pairs requested within two
calendar years. These limitations also apply to fittings and
adjustments.
(b) Additional
eyeglasses which are medically necessary may be prior authorized by Medicaid
for treatment of eye injury, disease or significant prescription
change.
(c) The provider should
forward a letter to Medicaid justifying medical necessity prior to ordering the
eyeglasses (reference Rule No.
560-X-17-.01(3).
(d) A response of either approval or denial
will be returned to the provider. If approved, a prior authorization number
will be assigned (reference Rule No.
560-X-17-.01(3)
(e) If a patient desires frames or
lenses other than those covered by Medicaid he/she must pay the complete cost
of the eyeglasses, including fitting and adjusting; Medicaid will not pay any
part of the charge. To prevent possible later misunderstanding, the provider
should have the patient sign the following statement for retention with the
patient's records: "I hereby certify that I have been offered Medicaid
eyeglasses but prefer to purchase the eyeglasses myself."
(2) Procurement. At the option of the
provider making the frame measurements, eyeglasses in conformance with Medicaid
standards, may be procured from either the central Medicaid source or from any
other source. Medicaid will pay no more than the contract price charged by the
central source.
(3) Standards and
Price of Frames.
(a) A list of authorized
frames and contract prices is available in the Alabama Medicaid Provider
Manual.
(b) The authorized frames,
or frames of equal quality, will be provided for Medicaid recipients at the
contract prices shown on the list. (Under normal circumstances the date of
service for eyeglasses will be the same as the date of examination.)
(c) Patients having old frames, which meet
Food and Drug Administration (FDA) impact-resistant regulations and conform to
ANSI requirements may have new lenses installed in lieu of being issued new
eyeglasses. Medicaid will pay for the lenses only. The following statement
should be documented in the recipient's record: "I hereby certify that I used
this patient's old frames and that I did not accept any remuneration
therefore."
(d) Services provided
under this sub-paragraph are subject to the program benefit
limitations.
(4) Lenses.
(a) Lens specifications are authorized at the
specified contract price.
(b)
Lenses will be of clear glass, plastic, or polycarbonate unless prior
authorized by Medicaid because of unusual conditions, as indicated in Rule
560-X-17-.01(3).
All lenses will meet FDS impact-resistant regulations.
(c) Spherical lenses must be at least a plus
or minus .50 diopters; the minimum initial correction for astigmatism only (no
other error) is .50 diopters.
(5) Services.
Services reimbursed for eyeglass procurement are: eye
examination, including refraction; filling the lens prescription; supplying the
frame; and frame fitting, including frame service, verification, and subsequent
service.
Author: Elizabeth Huckabee, Program Manager;
Physician and EPSDT Unit
Statutory Authority: State Plan; Title XIX,
Social Security Act;
42 C.F.R. §
435.520(3),
441.30(a)(b);
State Plan, Attachment 3.1-A, pages 2.2, 5.1.
