Current through Register Vol. 49, No. 18, September 16, 2024
PURPOSE: This amendment updates the requirements
related to precertification of Optical Program services, adds record retention
language, clarifies provider enrollment requirements for certain services,
identifies optometrists as acceptable providers for prescribing contact lenses
for therapeutic purposes, and updates terminology as
appropriate.
(1)
Administration. The Department of Social Services, MO HealthNet Division shall
administer the Optical Program. The Department of Social Services, MO HealthNet
Division shall determine, and include in the Optical Provider manual, the
optical services covered and not covered, the program limitations, and the
maximum allowable fees for all covered services. The Optical Provider manual is
incorporated by reference and made a part of this rule as published by the
Department of Social Services, MO HealthNet Division, 615 Howerton Court,
Jefferson City, MO 65109, at its website at website at
http://manuals.momed.com/collections/collection_opt/print.pdf
November 24, 2020. This rule does not incorporate any subsequent amendment or
additions. Services covered shall include only those which are clearly shown to
be medically necessary.
(2)
Participants Eligible. Any participant who is eligible for MO HealthNet
benefits as determined by the Family Support Division and who is found to be in
need of optical services as described in this regulation subject to the
limitations set forth in subsections (7)(A)-(X).
(3) Provider Participation. To be eligible
for participation in the MO HealthNet Optical Program, a provider must meet the
criteria specified for his/her profession as follows:
(A) An optometrist must be a duly licensed
Doctor of Optometry (OD) to participate in the MO HealthNet program, must be
licensed in accordance with the licensing provisions of the state in which s/he
practices, and must have a current MO HealthNet participation agreement and
provider number;
(B) A physician
must be a duly licensed Doctor of Medicine (MD) or Doctor of Osteopathy (DO) to
participate in the MO HealthNet program, must be licensed in accordance with
the licensing provisions of the state in which s/he practices, and must have a
current MO HealthNet participation agreement and provider number;
(C) A clinic can participate in the Optical
Program if it has a current MO HealthNet Program clinic number. In addition to
the clinic number, each of the performing optometrists must have an effective
participation agreement and MO HealthNet program provider number. Reimbursement
may be made to the clinic for all covered services provided at the clinic;
and
(D) An optician, optical
dispenser, or manufacturer of prosthetic eyes must have a current MO HealthNet
participation agreement and provider number.
(4) Types of Service Reimbursed by the MO
HealthNet Program for Each Profession.
(A)
Optometrist or Clinic.
1. Eye
examinations.
2.
Refractions.
3.
Eyeglasses
4. Prosthetic
eyes.
5. Special ophthalmological
services (Clinic only).
(B) Opticians or Optical Dispensers.
1. Eyeglasses.
2. Prosthetic eyes.
(C) Manufacturers of Prosthetic
Eyes-Prosthetic Eyes.
(D)
Physicians (MD or DO).
1. Eye
examinations.
2.
Refractions.
3. Eyeglasses (Must be
enrolled as an Optical provider).
4. Prosthetic eyes (Must be enrolled as an
Optical provider).
5. Special
ophthalmological services.
(5) Reimbursement. MO HealthNet reimbursement
will be the lower of the provider's usual and customary charge to the general
public or the MO HealthNet allowable amount.
(6) Covered Services.
(A) Complete or limited eye examination
(B) Eye refraction
(C) Eyeglasses.
(D) Frames.
(E) Temple.
(F) Lenses, single vision.
(G) Lenses, bifocal.
(H) Lenses, trifocal.
(I) Lenses, cataract.
(J) Special frames.
(K) Special lenses.
(L) Miscellaneous repairs.
(M) Scleral cover shell, stock, or custom.
(N) Prosthetic eye, plastic, or
custom.
(O) Prosthetic eye,
refitting.
(P) Prosthetic eye
check/polish-ing/cleaning.
(Q)
Rose I and Rose II tints.
(R)
Photochromatic lenses.
(S)
Orthoptic and/or pleoptic training, with continuing optometric direction and
evaluation (visual therapy/training).
(T) Fitting of contact lens for treatment of disease,
including supply of lens (therapeutic bandage lens).
(U) Visual field examination with optometric
diagnostic evaluation; tangent screen, autoplot, or equivalent.
(V) Electro-oculography, with medical
diagnostic evaluation.
(W)
Visually evoked potential (response) study, with medical diagnostic
evaluation.
(X) Quantitative
perimetry, for example, several isopters on Goldmann perimeter or
equivalent.
(Y) Static and kinetic
perimetry or equivalent.
(Z)
Serial tonometry with optometric diagnostic evaluation (separate procedure),
one (1) or more sessions, same day.
(AA) Tonography with optometric diagnostic evaluation,
recording indentation tonometer method or perilimbal suction method.
(BB) Color vision examination, extended, for
example, anomaloscope or equivalent.
(CC) Dark adaptation examination, with
optometric diagnostic evaluation.
(7) Program Limitations.
(A) Optical Program services require
pre-certification. Precertification serves as a utilization management tool,
allowing payment for services that are medically necessary, appropriate, and
cost effective without compromising the quality of care to participants. An
enrolled optical provider must initiate requests for pre-certification and MO
HealthNet must issue approval before delivery of service. The pre-certification
medical criteria can be found in the Optical Provider Manual identified in
section (1) of this rule.
(B) One
(1) comprehensive or one (1) limited eye examination is allowed per two (2)
years (within a twenty-four- (24-) month period of time) under the MO HealthNet
program. Eligible children, pregnant women, individuals residing in a nursing
home, and blind persons are allowed one (1) comprehensive or one (1) limited
eye examination per year (within a twelve- (12-) month period of time) under
the MO HealthNet program. Payment for a comprehensive eye examination will be
made only if six (6) or more of the following procedures have been performed:
1. Refraction far point and near
point;
2. Case history;
3. Visual acuity testing;
4. External eye examination;
5. Pupillary reflexes;
6. Ophthalmoscopy;
7. Ocular motility testing;
8. Binocular coordination;
9. Vision fields;
10. Biomicroscopy (slit lamp);
11. Tonometry;
12. Color vision; and
13. Depth perception.
(C) If fewer than six (6) of these are
performed, a limited examination must be billed.
(D) Eligible children, pregnant women, individuals
residing in a nursing home, and blind persons may be allowed additional eye
examinations during the year (within a twelve- (12-) month period of time) if
medically necessary (that is, cataract examination, prescription change of 0.50
diopters or greater).
(E)
Eyeglasses are covered by the MO HealthNet program for MO HealthNet eligible
individuals when the prescription is at least 0.75 diopters for one (1) eye or
0.75 diopters for each eye.
(F)
Only one (1) pair of eyeglasses is allowed every two (2) years (within any
twenty-four- (24-) month period of time) for MO HealthNet eligible
individuals.
(G) The original
eyeglass prescription and laboratory invoices listing costs for optical
materials, lenses, and/or frames provided; and the charge for grinding, edging,
or assembling of glasses must be kept on file by the provider for six (6) years
and furnished to the MO HealthNet Division or its representative upon
request.
(H) Special frames are
covered under the MO HealthNet program if they are required for medical
reasons. Special frames may be authorized if the patient requires special
lenses (plus or minus 4.00 diopters for one (1) eye or plus or minus 4.00
diopters for each eye and are extra thick or heavy), the structure of the
patient's face requires special frames (a very large face, wide-set eyes), or
the patient needs glasses with pads because of nose surgery.
(I) Special lenses are covered under the MO
HealthNet program if they are medically justified and the prescription is plus
or minus 4.00 diopters for one (1) eye or plus or minus 4.00 diopters for each
eye, cataract lenses, or special bifocal lenses (for example, plastic Executive
lenses).
(J) Plastic lenses may
be dispensed under the MO HealthNet program. Reimbursement will be at the same
rate as comparable glass lenses. Additional payment will be allowed for plastic
lenses that meet the definition of special lenses and are medically
justified.
(K) Photochromatic
lenses are covered only if medically necessary.
(L) Tinted lenses (Rose I and Rose II) are covered if
medically necessary.
(M)
Replacement of optical materials and repairs in excess of program limitations
may be covered if medically necessary, or required for employment training, or
educational purposes, as follows:
1.
Replacement of complete eyeglasses (frames and lenses).
A. Lenses and frames broken (participant must
show provider the broken glasses or the MO HealthNet program will not pay for
the glasses).
B. Lost.
C. Destroyed.
D. Stolen.
E. Repair of existing glasses would exceed
the MO HealthNet allowable amount for new frames and lenses;
2. Lenses-if medically necessary.
A. Scratched.
B. Broken.
C. Prescription change of at least 0.50
diopters or greater; or
3. Frames-Temples, fronts, or both broken and
repair would exceed the MO HealthNet allowable amount for new
frames.
(N) Repair of
frames or replacement of parts of frames (temples) are covered as follows:
1. The cost of the repairs do not exceed the
MO HealthNet allowable amount for new frames; and
2. Repair would provide a serviceable frame
for the participant.
(O) Temples may never be billed in addition to
complete new eyeglasses and new frames.
(P) An eye refraction may be reimbursed in addition to
a comprehensive or limited eye examination. Because an eye refraction is not
covered by Medicare but is covered by MO HealthNet, providers may bill MO
HealthNet for an eye refraction when the patient has Medicare and MO HealthNet
coverage.
(Q) Eyeglasses may be
covered by MO HealthNet for a prescription of less than 0.75 diopters if
medically necessary. Eyeglasses less than 0.75 diopters will be approved for
the following reasons:
1. Child age twenty
(20) and under who requires glasses for school performances;
2. Visual acuity 20/40 or less; or
3. Protective eyewear for participants with
sight in only one (1) eye.
(R) Any warranties extended by optical companies for
optical materials to private-pay patients must also apply to those same
materials dispensed to MO HealthNet participants.
(S) The MO HealthNet program allows one (1) prosthetic
eye per eye (one (1) left and one (1) right) within a five-(5-) year period. If
the prosthetic eye is lost, destroyed, cracked, or deteriorated, payment will
be allowed for replacement.
(T)
Optometrists may be reimbursed for visual therapy training when there is a
prognosis for substantial improvement or correction of an ocular or vision
condition. These conditions include amblyopia, eccentric (nonfoveal) monocular
fixation, suppression, inadequate motor or sensory fusion, and strabismus
(squint). The number of training sessions is limited to one (1) per day, two
(2) per week, and a maximum of twenty (20) sessions. If the patient shows
significant improvement after the initial twenty (20) sessions and the
optometrist feels that further progress could be made, additional training
sessions not to exceed a total of forty (40) sessions may be
provided.
(U) Fitting of contact
lens for treatment of disease, including supply of lens (therapeutic bandage
lens) is covered if it is prescribed by a physician (MD or DO) or optometrist
(OD) as a bandage to cover a diseased condition of the eye, such as a bandage
over an abrasion of the skin. The lens must be plain with no corrective power.
Diagnosis for which the lens should be reimbursed are Bullous Kerotopathy,
Corneal Ulcers, Ocular Pemphigoid, and other corneal exposure
problems.
(V) Visual field
examination with optometric diagnosis evaluation, tangent screen autoplot, or
equivalent is covered when performed by an optometrist.
(W) Quantitative perimetry, for example, several
isopters on Goldmann perimeter, or equivalent is covered.
(X) Serial tonometry with optometric diagnostic
evaluation (separate procedure), one (1) or more sessions on the same day is
covered when performed by an optometrist. Routine tonometry is included in the
reimbursement for a comprehensive examination and cannot be billed
separately.
(8)
Noncovered Services.
(A) Eyeglass frames with
hearing aids attached.
(B) Optical
services or materials provided to a participant who was not eligible on the
date the service was provided or the optical materials were delivered to the
patient.
(C) Sales or use tax on
optical materials (the participant is not responsible for and may not be billed
for such taxes).
(D) Contact lenses
other than for medical purposes as described above in subsection
(7)(S).
(E) Sunglasses.
(F) Lenses exceeding 65 mm in diameter or
frames for such lenses.
(G)
Temporary lenses for cataract lenses.
(H) Eyeglass cases.
(I) Monicals.
(J) Magnifiers.
(K) Eye medications.
(L) Repair of old frames if the repair
exceeds the cost of new frames.
(M)
Replacement of optical materials resulting from patient abuse.
(N) Optical materials which are not medically
necessary.
(O) Nose pads.
(P) Eyeglass adjustments.
(Q) Optical materials not meeting MO
HealthNet Division standards.
(R)
Lenses or frames supplied incorrectly to the provider by the supplier or
manufacturer.
(S) Replacement of
lenses, complete eyeglasses, frames, or prosthetic eyes supplied incorrectly to
participant by optical provider.
(T)
Optical materials in excess of those authorized within the benefit
period.
(9) General
Regulations. This rule shall not encompass all of the general regulations of
the MO HealthNet program. These regulations, however, shall be in effect for
the optical section of the overall program.
(10) Records Retention. MO HealthNet may
impose sanctions against a provider for failure to make available or disclose
to the MO HealthNet agency or its authorized agents, all records relating to
services provided to MO HealthNet participants or records related to MO
HealthNet payments, whether or not the records are comingled with non-MO
HealthNet records, in compliance with
13 CSR
70-3.030. Providers must retain these records for six
(6) years from the date of service. Fiscal and medical records must coincide
with, and fully document, services billed to the MO HealthNet agency. Providers
must furnish or make the records available for inspection or audit by the
Department of Social Services or its representative upon request.
