Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid
agency covers the following plastic scratch-resistant eyeglass lenses :
(a) Single vision lenses;
(b) Round or flat top D-style
bifocals;
(c) Flat top trifocals;
(d) Slab-off and prism lenses
(including Fresnel lenses);
(e)
Plastic photochromatic lenses when the client's medical need is diagnosed and
documented as ocular albinism or retinitis pigmentosa;
(f) Polycarbonate lenses when the client's
medical need is diagnosed and documented as one of the following:
(i) Blind in one eye and needs protection for
the other eye, regardless of whether a vision correction is required;
(ii) Infants and toddlers with motor
ataxia;
(iii) Strabismus or
amblyopia;
(iv) Seizure disorder,
cerebral palsy, autism, attention deficit hyperactivity disorder (ADHD),
developmental delay, Down syndrome, bipolar, schizophrenia, or multiple
sclerosis.
(g) Bifocal
lenses to be replaced with single vision or trifocal lenses, or trifocal lenses
to be replaced with bifocal or single vision lenses when:
(i) The client has attempted to adjust to the
bifocals or trifocals for at least sixty days;
(ii) The client is unable to make the
adjustment; and
(iii) The trifocal
lenses being replaced are returned to the provider.
(2) Eyeglass lenses covered under
subsection (1) of this section must be placed into a frame that is, or was,
purchased by the agency.
(3) The
agency covers the following high index lenses for clients when clinical
criteria are met. The client's medical need in at least one eye must be
diagnosed and documented as:
(a) A spherical
refractive correction of plus or minus six diopters or greater; or
(b) A cylinder correction of plus or minus
three diopters or greater.
(4) The agency covers the tinting of plastic
lenses when the client's medical need is diagnosed and documented as one or
more of the following chronic (expected to last longer than three months) eye
conditions causing photophobia:
(a)
Blindness;
(b) Chronic corneal
keratitis;
(c) Chronic iritis,
iridocyclitis;
(d) Diabetic
retinopathy;
(e) Fixed
pupil;
(f) Glare from
cataracts;
(g) Macular
degeneration;
(h) Migraine
disorder;
(i) Ocular
albinism;
(j) Optic atrophy or
optic neuritis;
(k) Rare
photo-induced epilepsy conditions; or
(l) Retinitis pigmentosa.
(5) The agency covers up to four
replacement lenses in a calendar year when the lenses are lost or broken. Lost
or broken lenses must be documented in the client's medical record.
(6) The agency covers replacement lenses when
the client meets one of the following clinical criteria:
(a) Eye surgery or the effects of prescribed
medication or one or more diseases affecting vision:
(i) The client has a stable visual
condition;
(ii) The client's
treatment is stabilized;
(iii) The
lens correction must have a 1.0 or greater diopter change between the sphere or
cylinder correction in at least one eye; and
(iv) The previous and new refraction are
documented in the client's medical record.
(b) Headaches, blurred vision, or visual
difficulty in school or at work. In this case, all of the following must be
documented in the client's medical record:
(i) Copy of current prescription (less than
eighteen months old);
(ii) Date of
last dispensing, if known;
(iii)
Absence of a medical condition that is known to cause temporary visual acuity
changes (e.g., diabetes, pregnancy, etc.); and
(iv) A refractive change of at least .75
diopter or greater between the sphere or cylinder correction in at least one
eye.
11-14-075, recodified as §182-544-0350, filed
6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.08.090. 11-11-016, § 388-544-0350,
filed 5/9/11, effective 6/9/11. Statutory Authority:
RCW
74.08.090,
74.09.510,
74.09.520. 08-14-052, §
388-544-0350, filed 6/24/08, effective 7/25/08. Statutory Authority:
RCW
74.08.090,
74.09.510,
74.09.520, and
42 C.F.R.
440.120 and
440.225. 05-17-153, §
388-544-0350, filed 8/22/05, effective 9/22/05; 05-13-038, § 388-544-0350,
filed 6/6/05, effective 7/7/05. Statutory Authority:
RCW
74.08.090,
74.09.510 and
74.09.520. 01-01-010, §
388-544-0350, filed 12/6/00, effective
1/6/01.
