New York Codes, Rules and Regulations
Title 18 - DEPARTMENT OF SOCIAL SERVICES
Chapter II - Regulations of the Department of Social Services
Subchapter E - Medical Care
Article 3 - Policies and Standards Governing Provision of Medical and Dental Care
Part 505 - Charges For Professional Health Services
Section 505.6 - Ophthalmic services

(1) Qualified optometrist shall mean an optometrist who is licensed and currently registered by the New York State Education Department or, if in practice in another state, by the appropriate agency of that state.

(2) A qualified dispenser shall mean an ophthalmic dispenser who is licensed and currently registered by the New York State Department of Education or, if in practice in another state by the appropriate agency of that state.

(3) Low vision shall mean 20/70 or less in the best eye with best correction.

(1) Examinations for visual defects and/or eye disease shall be provided to medical assistance recipients only as necessary and as required by the individual's particular condition. For each medical assistance patient reimbursement for examinations shall be limited to once every two years unless otherwise justified as clinically necessary.

(2) Except in unusual circumstances, eyeglasses shall not be prescribed or provided for a person unless the initial correction or change in correction is at least 1/2 diopter. Any exception to this standard shall be clearly documented by the examining practitioner and shall require prior approval of the local professional director.

(3) Eyeglasses shall be provided only on the basis of proper examination by and with a written prescription of a licensed opthalmologist or optometrist. Eyeglasses shall not normally require changing more frequently than every two years. Any exception to this standard shall be justified as being clinically necessary.

(4) When dispensing eyeglasses, the optometrist or opthalmic dispenser shall complete the following tasks:

(5) Fabrication of eyeglasses shall conform to the current American National Standards Institute (ANSI) prescription requirements.

(6) The following standards shall be observed in providing lenses and frames:

(7) Provision of two pairs of eyeglasses, one pair for distance and one for near vision shall not be made unless the need for such pairs shall be substantiated by the patient's particular needs, such as proven inability to tolerate bifocals, the unusual nature of the patient's correction, physical ailments, and other conditions which make provision of bifocals inadvisable. Two pairs of eyeglasses shall not be provided merely as an alternative to satisfy an unjustifiable preference on the part of the patient, for personal convenience or for cosmetic purposes.

(8) For each medical assistance patient examined, a proper record must be maintained by the service provider(s) and, if applicable to the service provided, must include the following information:

(9) An eye examination provided by a qualified optometrist to be accepted as the basis for prescription for eyeglasses to be reimbursable under medical assistance program shall include, as a minimum, the following components:

(10) A complete examination by an ophthalmologist shall include the minimal components listed in paragraph (9) of this subdivision and any additional study and medical evaluation including the use of drugs, necessary to arrive at a medical diagnosis.

(11) Optometrists may perform low vision examinations only after passing a qualifying examination in low vision given by the New York State Optometric Association. Prior approval shall not be required for a low vision examination when performed by a licensed ophthalmologist or qualified optometrist.

(12) State reimbursement or payment shall not be available for a low vision examination when such examination is included in and part of any other eye examination and/or eye refraction provided by a practitioner to an individual patient.

(13)

(14) Artificial eyes require the recommendation of a licensed opthalmologist and shall require approval by the local professional director.

(15) Contact lenses shall be supplied only for the treatment of ocular pathology and shall require the written recommendation or prescription of a licensed opthalmologist. Prior approval by the local professional director shall be required for all contact lens services.

(1) The identification card issued to persons eligible for medical assistance shall constitute full authorization for providing the following services and supplies and no special or prior approval shall be required:

(2) Prior approval of the local professional director shall be required for the following supplies:

(1) The department will purchase from the Department of Correctional Services all eyeglass lenses and frames to be furnished under the medical assistance (MA) program to recipients of MA and the Department of Correctional Services will assume full responsibility for the provision of such eyeglass lenses and frames to optometrists, qualified dispensers, and retail optical establishments for dispensing to recipients of MA in accordance with the provisions of this subdivision.

(2) Prior to the Department of Correctional Services' assumption of responsibility for providing such eyeglass lenses and frames, the Department of Correctional Services will enter into an agreement with the department for the acquisition of eyeglass lenses and frames by the department and for distribution of such eyeglass lenses and frames by the Department of Correctional Services to enrolled optometrists, qualified dispensers, and retail optical establishments. Such agreement will provide for the prompt provision of ordered supplies, assure that the supplies provided meet appropriate fabrication requirements and standards, and contain such other provisions as the department and the Department of Correctional Services deem appropriate for the efficient and effective distribution of such materials. For purposes of this subdivision, the Department of Correctional Services will guarantee lenses, frames, and frame parts against defects in manufacture or assembly and will be responsible for any needed replacements or repairs that are due to defects in quality of material or workmanship.

(3) On and after the dates specified below, optometrists, qualified dispensers, and retail optical establishments must obtain from the Department of Correctional Services all eyeglass lenses and frames to be dispensed under the MA program to recipients of MA, who have received their authorizations for MA from the following specified social services districts:

(4)

(5) This subdivision will be effective only if Federal financial participation is available for services provided hereunder to recipients of MA in federally participating categories of assistance.

(6) Optometrists, qualified dispensers and retail optical establishments rendering supplies to recipients of MA, who have received their authorizations from the above-specified social services districts, may obtain eyeglass lenses and frames from qualified sources other than the Department of Correctional Services upon written approval by the department. Such written approval may be granted in circumstances where the department determines that the Department of Correctional Services cannot perform its obligations under its agreement with the department.

(7) The provisions of this subdivision do not apply to eyeglass lenses and frames provided to recipients of MA who: