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 4 - Fees and Reimbursement
Part 537 - State Reimbursement For Optometric Services
Section 537.4 - Reimbursement for payments to dispensing opticians and other retail optical establishments
Current through Register Vol. 46, No. 39, September 25, 2024
(a) The maximum reimbursable allowance for services of dispensing opticians and other retail optical establishments (including salaried optometrists employed by retail optical establishments) shall be as follows:
FEES FOR LENSES AND FRAMES
First or single pair of eyeglasses
| Code | Item | Fee | Remarks2 |
| E601 | Single vision, standard chart thickness | ** | 1 |
| E651 | hardening and testing * | $2.22 | |
| E661 | tinting | ** | prior approval |
| E701 | Single vision, over-standard chart thickness | ** | prior approval |
| E751 | hardening and testing * | $3.70 | prior approval |
| E761 | tinting | ** | prior approval |
| E801 | Bifocals | ** | |
| E851 | hardening and testing * | $4.00 | |
| E861 | tinting | ** | prior approval |
| E901 | Trifocals | ** | |
| E951 | hardening and testing * | $4.44 | |
| E961 | tinting | ** | prior approval |
| E521 | Frame, wholesale cost up to $4.00 | ** | |
| E621 | Frame, wholesale cost more than $4.00 | ** | prior approval |
1 Prior approval required if correction is less than 1/2 diopter.
* Hardening, testing and markup (48%) included in this fee.
** Reimbursement at actual wholesale cost to the dispenser plus 48 percent above such cost. The following amounts will be accepted as minimum wholesale costs in computing the markup.
Single vision lenses and frames $5.50...............................
Bifocal lenses and frames 8.00.....................................................
Trifocal lenses and frames 13.00..........................................................
2 Remarks applicable only in the medical assistance program.
Second pair of eyeglasses (dispensed at same time)
| Code | Item | Fee | Remarks2 |
| E602 | Single vision, standard chart thickness | ** | |
| E652 | hardening and testing * | $2.22 | |
| E662 | tinting | ** | prior approval |
| E702 | Single vision, overstandard chart thickness | ** | prior approval |
| E752 | hardening and testing * | $3.70 | prior approval |
| E762 | tinting | ** | prior approval |
| E522 | Frame, wholesale cost up to $4.00 | ** | |
| E622 | Frame, wholesale cost more than $4.00 | ** | prior approval |
|
FEES FOR OTHER SERVICES |
|||
| E500 | Examination by a salaried optometrist 3 to include diagnosis for optical deficiency and for visual or musclar anomaly of the human eye | $5.004 | |
| E503 | Contact lenses-provided for ocular pathology only and recommended by an ophthalmologist | by report | prior approval |
| E571 | Adjustment by other than original provider | $2.00 | |
| E581 | Repair for replacement of broken parts (wholesale cost plus 60 percent markup over wholesale cost) minimum of | $2.00 | |
* Hardening, testing and markup (48%) included in this fee.
** Reimbursement at actual wholesale cost to the dispenser plus 48 percent above such cost. The following amounts will be accepted as minimum wholesale costs in computing the markup.
Single vision lenses and frames $5.50
Bifocal lenses and frames 8.00....................
Trifocal lenses and frames 13.00.......................
2 Remarks applicable only in the medical assistance program.
3 "Salaried optometrist" means a qualified optometrist employed by either a retail optical establishment or dispensing optician or a non-profit health service corporation as defined in article IX-C of the State Insurance Law.
4 The eye examination provided by a qualified salaried optometrist to be accepted as the basis for prescription of eyeglasses shall include, as a minimum, the components of an optometric examination contained in section 505.6 of the Title. Eye examinations which do not meet this standard will not be considered acceptable for purposes of payment from funds under public tax-supported medical care programs. Payment of this fee is effective August 1, 1975.
(b) The fees provided herein (including markup) are intended to cover all services performed by the above providers in connection with the dispensing of eyeglasses and will be considered full payment for services rendered under State-administered programs. Under the medical assistance program, which is administered by local social services districts, these fees (including markup) represent a maximum allowance for purposes of State reimbursement.
(c) Need for two pairs of eyeglasses, one pair for distance and one for near vision, should be uncommon. Such dispensing must 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 should not be provided merely as an alternative to bifocals to satisfy an unjustificable preference on the part of the patient, for personal convenience or for cosmetic purposes.
(d) The following standards shall be observed in providing lenses and frames.
