Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1147 - OPTOMETRISTS' SERVICES
PAYMENT FOR OPTOMETRIC SERVICES
Section 1147.53 - Limitations on payment
Current through Register Vol. 54, No. 12, March 23, 2024
(a) A vision examination is compensable only at the fee established in the MA Program fee schedule regardless of whether the optional components described in § 1147.2 (relating to definitions) are provided.
(b) Eyeglasses are limited to one full pair or two lenses per year. These are compensable only for eligible recipients who have received prior authorization from the Department or are receiving the eyeglasses under the EPSDT program or the School Medical program as described in Chapter 1101 (relating to general provisions).
(c) Low vision aids are limited to one per recipient per 2 years.
(d) Eye prostheses are limited to one per recipient per 2 years. These are compensable only for categorically needy recipients.
(e) Contact lenses are only compensable when used as a prostheses, such as, to replace the lens of the eye.
(f) Optometric services are compensable when provided in a clinic. The clinic is considered the provider and is responsible for billing the Department for services as defined in § 1221.51(5) (relating to general payment policy).
The provisions of this § 1147.53 issued under sections 403(a) and (b) and 443.6 of the Public Welfare Code (62 P. S. §§ 403(a) and (b) and 443.6).
This section cited in 55 Pa. Code § 1147.12 (relating to outpatient services); 55 Pa. Code § 1147.13 (relating to inpatient services); and 55 Pa. Code § 1147.51 (relating to general payment policy).
