New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 62 - VISION CARE SERVICES MANUAL
Subchapter 2 - OPTICAL APPLIANCES AND SERVICES
Section 10:62-2.4 - Covered optical appliances and related services
Universal Citation: NJ Admin Code 10:62-2.4
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The following optical appliances and related services are covered under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs. In order to determine whether an optical appliance or related service requires prior authorization, and for details regarding such prior authorization, see N.J.A.C. 10:62-2.5.
1. Optical lenses (see
10:62-2.6);
2. Optical frames (see
10:62-2.7);
3. Repairs of optical appliances;
4. Artificial eyes may be provided once every
three years when prescribed by an ophthalmologist or an optometrist;
5. Low vision devices;
6. Vision training devices;
7. Replacement of optical appliances:
i. Lenses and frames may be replaced once
every two years for persons age 19 through and including 59 years of age, and
once a year for persons less than 19 years or 60 years of age and older,
provided there is a change of 0.50 diopter in sphere and or cylinder power, or
a change of five degrees or more in cylinder axis.
ii. Lenses may be replaced more frequently
than once every two years for persons 19 through and including 59 years of age
or more frequently than once every year for persons less than 19 years or 60
years of age and older, providing there is a prescription change of at least
0.75 diopter in spherical and/or cylindrical power or a change in axis of eight
degrees or more. Providers shall enter the previous prescription number in the
Remarks section (#19) of the MC-9 claim form.
iii. When an optical appliance is destroyed
in a fire or stolen, the provider shall place a written statement in the
Remarks section (#19) of the MC-9 claim form and put a copy of the fire/police
report in the provider's beneficiary's file.
iv. Providers may provide one replacement of
frame and/or lenses per year for individuals with developmental disabilities.
Provider shall place a written supporting statement and diagnosis related
information in the Remarks section (#19) of the MC-9 claim form and put a copy
of the developmental disabilities report in the provider's beneficiary's
file.
v. Contact lenses will be
provided once every two years for persons age 19 through and including 59 years
of age, and once a year for persons up to age 19 or 60 years of age and older.
(1) Replacement of a contact lens in less
than the timeframes in this subparagraph is allowed only if there is a need for
a change in the fit or design of the lens or if there has been a prescription
change of 0.50 diopter in spherical or astigmatic power. The need for a
replacement due to a change in the fit or design of the lens shall be
determined by the vision care professional based on an examination of the
patient.
8.
Dual pairs of glasses instead of multifocal;
9. Contact lenses;
10. Polycarbonated or ultraviolet filter
lenses, when recommended by the prescribing practitioner as medically
necessary;
11. Intraocular lenses;
and
12. Protective prescription
eyewear that is needed by a specific child beneficiary because it is required
pursuant to
N.J.S.A.
5:18-1 while the child participates in
sports.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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