DAR File No. 32226

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-53

Eyeglasses Services

NOTICE OF PROPOSED RULE

DAR File No.: 32226
Filed: 12/17/2008, 05:37
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to comply with budget reduction mandates set forth in the 2008 Second Special Session of the Utah Legislature.

Summary of the rule or change:

This change allows only pregnant women and individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT) to receive eyeglasses services. It further removes the $3 copayment for eyeglasses that the Department currently applies to recipients who fall under the copayment requirement.

State statutory or constitutional authorization for this rule:

Section 26-18-3

Anticipated cost or savings to:

the state budget:

The Department estimates an annual savings of $231,252 to the General Fund and $558,275 in federal dollars as a result of this change. These estimates also apply to Rule R414-52 Optometry Services, which is a companion filing to this proposed rule. (DAR NOTE: The proposed filing on Rule R414-52 is under DAR No. 32225 in this issue, January 15, 2009, of the Bulletin.)

local governments:

This change does not impact local governments because they do not fund or provide eyeglasses services to Medicaid clients.

small businesses and persons other than businesses:

Providers of eyeglasses services will lose approximately $789,528 in annual revenue as a result of this change. However, the total out-of-pocket expense to Medicaid clients who elect to pay out-of-pocket to receive eyeglasses is difficult to estimate because it is impossible to know how many clients would choose this option. Further, there are a wide range of options and prices available for eyeglasses. The above estimate and explanation also apply to Rule R414-52 Optometry Services, which is a companion filing to this proposed rule.

Compliance costs for affected persons:

The annual loss in revenue to a single provider of eyeglasses is approximately $43,863 based on the total number of providers and client visits per year. However, the annual out-of-pocket expense to a single Medicaid client who elects to pay out-of-pocket to receive eyeglasses is difficult to estimate because it is impossible to know how many clients would choose this option. Further, there are a wide range of options and prices available for eyeglasses. The above estimate and explanation apply to Rule R414-52 Optometry Services, which is a companion filing to this proposed rule.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule change reflects the reductions passed in S.B. 2001 (2008 2nd Spec Sess) and are necessary to file under emergency authority to immediately implement the budget reductions. David N. Sundwall, MD, Executive Director (DAR NOTE: S.B. 2001 (2008 2nd Spec Sess) is found at Chapter 2, Laws of Utah 2008 (2nd Spec Sess) and was effective 09/29/2008.)

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

02/17/2009

This rule may become effective on:

02/24/2009

Authorized by:

David N. Sundwall, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-53. Eyeglasses Services.

R414-53-3. Client Eligibility Requirements.

Eyeglasses are available only to clients who are [categorically and medically needy individuals]pregnant women or who are individuals eligible under the Early and Periodic Screening, Diagnosis and Treatment Program.

 

R414-53-5. Reimbursement.

(1) The Department pays for lenses and standard frames on a fee-for-service basis, based on CPT codes as described in the State Plan, Attachment 4.19-B.[ A $3 copayment for each pair of eyeglasses is applied to Medicaid recipients who fall under the copayment requirement.]

(2) The Department pays the lower of the amount billed or the rate on the schedule. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private-pay patients.

(3) Fee schedules were initially established after consultation with provider representatives. Adjustments to the schedule are made in accordance with appropriations and to produce efficient and effective services.

 

KEY: Medicaid, eyeglasses

Date of Enactment or Last Substantive Amendment: [February 1, 2008]2009

Notice of Continuation: June 5, 2008

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3