Current through Register Vol. 48, No. 38, September 20, 2024
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.
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 additional pair of
eyeglasses or set of lenses within a 24-month period for adults 21 years of age
and older after eye surgery.
