Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-6 - Vision Care Services
Section 5160-6-01 - Eye care services
Universal Citation: OH Admin Code 5160-6-01
Current through all regulations passed and filed through September 16, 2024
(A) Scope. This rule sets forth general coverage and payment policy for eye care services. Additional provisions for eye care services provided through a medicaid managed care organization are described in Chapter 5160-26 of the Administrative Code.
(B) Definitions.
(1)
"Eligible provider" has the same meaning as in rule
5160-1-17 of the Administrative
Code.
(2)
"Eye care services" is a collective term for the
following services and materials involving the health of the eyes:
(a)
Vision care
services, which include the following procedures:
(i)
Diagnostic and
comprehensive examination;
(ii)
Testing;
(iii)
Therapeutic
treatment;
(iv)
Lens fitting; and
(v)
Vision
therapy;
(b)
Vision care materials, which include the following
items:
(i)
Spectacle lenses and frames; and
(ii)
Contact
lenses;
(c)
Low-vision aids; and
(d)
Ocular prostheses
and prosthesis services.
(3)
"Participating
optical laboratory" is an optical laboratory that is a party to the volume
purchasing contract.
(4)
"Prior authorization" has the same meaning as in rule
5160-1-31 of the Administrative
Code.
(5)
"Volume purchase contract," for purposes of this rule,
is the current contract designated "medicaid vision volume purchase program:
ophthalmic laboratory services and delivery" that is maintained by the Ohio
department of administrative services. The contract can be accessed at
https://ohiobuys.ohio.gov/page.aspx/en/ctr/contract_browse_public.
(C) Providers.
(1)
Rendering
providers. The following eligible providers may receive medicaid payment for
rendering an eye care service:
(a)
Eye care professionals (such as ophthalmologists,
optometrists, opticians, and ocularists) acting within their scope of practice
in accordance with Chapter 4725. or Chapter 4731. of the Revised Code and
furnishing services in accordance with professional standards;
and
(b)
For the provision of spectacle lenses and frames, a
participating optical laboratory.
(2)
Billing ("pay
to") providers. The following entities may receive medicaid payment for
submitting a claim for an eye care service on behalf of a rendering
provider:
(a)
A
rendering provider;
(b)
A professional organization (group practice or
partnership) of ophthalmologists, optometrists, opticians, ocularists, or a
combination of these practitioners organized under Chapter 1785. of the Revised
Code for the sole purpose of providing vision care services;
(c)
An ambulatory
health care clinic described in Chapter 5160-13 of the Administrative Code;
or
(d)
A federally qualified health center (FQHC) described in
Chapter 5160-28 of the Administrative Code.
(D) Coverage.
(1)
Vision care
services.
(a)
Payment may be made for the following classes of
service:
(i)
General ophthalmological services; and
(ii)
Spectacle
fitting.
(b)
Certain specialized ophthalmological services are
identified as diagnostic or therapeutic procedures comprising both professional
and technical components. Payment for these services is made in accordance with
Chapter 5160-4 of the Administrative Code.
(c)
Coverage of other
individual procedures is indicated in appendix DD to rule
5160-1-60 of the Administrative
Code.
(d)
If an examination and a fitting are performed by the
same provider, then the date of the examination may be used as the initial date
of fitting.
(e)
Vision care services are subject to the following
copayments per date of service per claim unless the individual is excluded from
the copayment provision pursuant to rule
5160-1-09 of the Administrative
Code:
(i)
Two
dollars for the following general ophthalmological services:
(a)
Ophthalmological
services: medical examination and evaluation with initiation of diagnostic and
treatment program, intermediate, new patient;
(b)
Ophthalmological
services: medical examination and evaluation with initiation of diagnostic and
treatment program, comprehensive, new patient, one or more
visits;
(c)
Ophthalmological services: medical examination and
evaluation, with initiation or continuation of diagnostic and treatment
program, intermediate, established patient; and
(d)
Ophthalmological
services: medical examination and evaluation, with initiation or continuation
of diagnostic and treatment program, comprehensive, established patient, one or
more visits; and
(ii)
One dollar for
the following dispensing services:
(a)
Fitting of spectacles, except for aphakia;
monofocal;
(b)
Fitting of spectacles, except for aphakia; bifocal;
and
(c)
Fitting of spectacles, except for aphakia; multifocal,
other than bifocal.
(2)
Vision care
materials.
(a)
Spectacle lenses and frames.
(i)
Payment may be
made without prior authorization (PA) for items and services listed in the
volume purchase contract that are provided by a participating optical
laboratory.
(ii)
Payment may be made with PA for items and services that
are categorized in the healthcare common procedure coding system (HCPCS) with
spectacle lenses and frames but are not listed in the volume purchase
contract.
(b)
Contact lenses.
(i)
Payment is
subject to PA, and each item may be ordered from an optical laboratory of the
provider's choice.
(ii)
A PA request may be denied if contact lenses have no
advantage over eyeglasses for the individual. This provision does not apply to
replacement contact lenses.
(iii)
Contact lenses
are deemed to have an advantage over eyeglasses in the treatment of any of the
conditions specified in the following non-exhaustive list of examples:
(a)
Aphakia;
(b)
Keratoconus;
(c)
Irregular corneal
astigmatism;
(d)
Corneal ectasia;
(e)
Post-operative
corneal irregularity;
(f)
Anisometropia with a difference of three or more
diopters; or
(g)
High ametropia in either eye of ten diopters or more
(either plus or minus).
(c)
Low-vision aids.
Payment is subject to PA, and each item may be ordered from an optical
laboratory of the provider's choice.
(d)
Ocular prostheses
and prosthesis services. Payment is subject to PA.
(3)
Subject to
age-based exceptions set forth in rule
5160-1-14 of the Administrative
Code, the following limits are established:
(a)
For an individual
twenty-one years of age or older but younger than sixty years of age, payment
for more than one comprehensive vision examination and one complete frame and
pair of lenses per twenty-four-month period is subject to PA.
(b)
For an individual
younger than twenty-one years of age or sixty years of age or older, payment
for more than one comprehensive vision examination and one complete frame and
pair of lenses per twelve-month period is subject to
PA.
(4)
A vision care provider may render service to an
individual living in a long-term care facility (LTCF) only after having
received a request signed by the individual, the individual's authorized
representative, or (if the authorized representative is not available) the
individual's attending physician.
(5)
Payment for the
following items and services is subject to PA:
(a)
Orthoptic or
pleoptic training;
(b)
Frames or lenses provided by a source other than a
participating optical laboratory, even if they are identical to items listed in
the volume purchase contract; and
(c)
Lenses prescribed
as supplementary sunglasses in addition to regular
eyeglasses.
(6)
No separate payment is made for both an evaluation and
management service and a general ophthalmological service performed during the
same visit.
(7)
The medicaid payment amount for a covered item is
compensation for the dispensing of that item. It cannot be used as a "credit"
toward payment for a substitute item. In particular, medicaid payment for a
covered frame listed in the volume purchase contract cannot be applied toward a
frame not listed in the contract. If no volume purchasing contract is currently
in effect, however, or if no frame suited to an individual's particular needs
is listed on the volume purchase contract, payment for spectacle lenses and
frames may be made to an eligible medicaid provider of vision care
services.
(8)
Nothing in this rule is to be construed as preventing a
medicaid-eligible individual from voluntarily paying out of pocket for a
non-covered additional service in accordance with rule
5160-1-13.1 of the
Administrative Code.
(E) Claim payment.
(1)
The payment amount for a covered vision care service is the lesser of the
submitted charge or the amount listed in appendix DD to rule
5160-1-60 of the Administrative
Code.
(2)
The payment amount for a covered spectacle lens or
frame listed in the volume purchase contract is determined by the terms of the
contract.
(3)
The payment amount for a covered spectacle lens or
frame not listed in the volume purchase contract is the lesser of the
provider's submitted charge or the provider's cost.
(4)
When vision care
is provided in an inpatient or outpatient hospital setting, payment for the
service is made in accordance with Chapter 5160-2 of the Administrative Code,
and payment for materials is made in accordance with this rule.
(5)
For a covered
vision care service furnished at a federally qualified health center (FQHC),
payment is made in accordance with Chapter 5160-28 of the Administrative
Code.
Replaces: 5160-6-01
Disclaimer: These regulations may not be the most recent version. Ohio 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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
