DAR File No. 39357

Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-53

Eyeglasses Services

Notice of Proposed Rule

(Amendment)

DAR File No.: 39357
Filed: 05/07/2015 11:15:37 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to consolidate the scope of eyeglasses services to the Medicaid provider manual.

Summary of the rule or change:

This amendment removes all provisions in the rule text and defers to the scope of services found in the Vision Care Services Utah Medicaid Provider Manual and in the Medicaid State Plan.

State statutory or constitutional authorization for this rule:

• Section 26-1-5
• 42 CFR 440.120
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because services provided to Medicaid recipients remain unaffected by this change.

local governments:

There is no impact to local governments because they do not fund or provide Medicaid services to Medicaid recipients.

small businesses:

There is no impact to small businesses because services provided to Medicaid recipients remain unaffected by this change.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and to Medicaid recipients because services provided to Medicaid recipients remain unaffected by this change.

Compliance costs for affected persons:

There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because services provided remain unaffected by this change.

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

The amendment does not impact business because it does not change the services currently provided to Medicaid recipients.

David Patton, PhD, Executive Director

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:

07/01/2015

This rule may become effective on:

07/08/2015

Authorized by:

David Patton, Executive Director

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

R414-53. Eyeglasses Services.

R414-53-1. Introduction.

The Eyeglasses Services Program provides a scope of services for Medicaid recipients in accordance with the Vision Care Services Utah Medicaid Provider Manual and Attachment 4.19-B of the Medicaid State Plan, as incorporated into Section R414-1-5.

[R414-53-1. Introduction and Authority.

The Eyeglasses Program provides eyeglasses services to meet the basic vision care needs of Medicaid recipients. This rule is authorized under Utah Code 26-18-3 and governs the services allowed under 42 CFR 440.120(d).

 

R414-53-2. Definitions.

"Eyeglasses" means lenses, including frames, contact lenses, and other aids to vision that are prescribed by a physician skilled in diseases of the eye or by an optometrist.

 

R414-53-3. Client Eligibility Requirements.

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

 

R414-53-4. Service Coverage.

(1) Corrective lenses and frames may be provided based on medical need. Medical need includes a change in prescription or replacement as a result of normal lens or frame wear. Frames must be those in which lenses can be replaced readily without having to provide a new frame. Corrective lenses must be suitable for indoor and outdoor use and for day and night use.

(2) Single vision, bifocal, or trifocal lenses, with or without slab-off prism, in clear glass or plastic, may be provided.

(3) Only the least expensive frame practicable for use, either plastic or metal, may be provided.

(4) Replacements for existing lenses or frames may be provided if the prescribing physician or optometrist documents that they are medically necessary. Eyeglasses may not be replaced more often than every two years unless the prescribing physician or optometrist documents that an earlier replacement is medically necessary. Circumstances that warrant providing new eyeglasses or contact lenses are a diopter change of .75 or more, or disease or damage to the eye. Eyeglasses or contact lenses may not be replaced if they are damaged through client negligence or abuse.

(5) The audiologist or hearing aid provider may provide frames that have hearing aids placed in the earpieces. The prescribing physician or optometrist must dispense the lenses for these frames.

(6) The following services may be provided if the prescribing physician or optometrist documents that they are medically necessary:

(a) Contact lenses;

(b) Soft contact lenses;

(c) Gas permeable contact lenses;

(d) Tints for eyeglasses or contact lenses where diseases or conditions are present that render the client unusually light-sensitive;

(e) Low vision aids.

(7) The following services are not provided:

(a) Additional eyeglasses such as reading glasses, distance glasses, or a "spare";

(b) Extended wear contact lenses or disposable contact lenses.

 

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.

(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 24, 2009]2015

Notice of Continuation: May 3, 2013

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