20110323-IR-405100794PRA Amends 405 IAC 5-23-2 to revise the age of recipients subject to limitations on the initial examinations from under 19 to under 21 years of age. Amends 405 IAC 5-23-4 to revise the age of recipients ...

TITLE 405 OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES

Proposed Rule LSA Document #10-794

DIGEST

Amends 405 IAC 5-23-2 to revise the age of recipients subject to limitations on the initial examinations from under 19 to under 21 years of age. Amends 405 IAC 5-23-4 to revise the age of recipients subject to the covered eyeglasses limitation from under 19 to under 21 years of age and amends that limitation from one pair every two years to one pair every five years. Effective 30 days after filing with the Publisher.

405 IAC 5-23-2; 405 IAC 5-23-4

SECTION 1. 405 IAC 5-23-2 IS AMENDED TO READ AS FOLLOWS:

405 IAC 5-23-2 Initial examinations

Authority: IC 12-8-6-5; IC 12-15

Affected: IC 12-13-7-3; IC 25-24-1-4

Sec. 2. (a) Reimbursement for the initial vision care examination will be limited to:

(1) one (1) examination per year for a recipient under nineteen (19) twenty-one (21) years of age; and

(2) one (1) examination every two (2) years for a recipient nineteen (19) twenty-one (21) years of age or older.

If medical necessity dictates more frequent examination or care, documentation of such medical necessity must be maintained in the provider's office. Such The documentation shall be subject to postpayment review and audit.

(b) An initial examination is the initial vision care service performed for the determination of the need for additional vision care services. Medical necessity will determine which type of initial exam will be given. The frequency of vision care services is subject to the limitations listed in subsection (a). The initial examination may include the following:

(1) An eye examination, including history.

(2) Visual acuity determination.

(3) External eye examination.

(4) Biocular measure.

(5) Routine ophthalmoscopy.

(6) Tonometry and gross visual field testing, including:

(A) color vision;

(B) depth perception; or

(C) stereopsis.

(Office of the Secretary of Family and Social Services; 405 IAC 5-23-2; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3343; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA)

SECTION 2. 405 IAC 5-23-4 IS AMENDED TO READ AS FOLLOWS:

405 IAC 5-23-4 Frames and lenses; limitations

Authority: IC 12-8-6-5; IC 12-15

Affected: IC 12-13-7-3; IC 25-24-1-4

Sec. 4. The provision of frames and lenses are subject to the following limitations:

(1) Reimbursement will be made for frames, including, but not limited to, plastic or metal. The maximum amount reimbursed for frames is twenty dollars ($20) per pair except when medical necessity requires a more expensive frame. Situations where medical necessity for a more expensive frame may be indicated include, but are not limited to, the following:

(A) Frames to accommodate facial asymmetry or other anomalies of the:

(i) head;

(ii) neck;

(iii) face; or

(iv) nose.

(B) Allergy to standard frame materials.

(C) Specific lens prescription requirements.

(D) Frames with special modifications such as a ptosis crutch.

(E) Provision of frames to an infant where special size frames must be prescribed that are unavailable for twenty dollars ($20) or less.

All Medicaid claim forms submitted for a more expensive frame must be accompanied by medical necessity documentation.

(2) Fashion tints, gradient tints, sunglasses, or photochromatic lenses are not covered. Tint numbers 1 and 2 are covered, for example, the following:

(A) Rose A.

(B) Pink 1.

(C) Soft lite.

(D) Cruxite. and

(E) Velvet lite.

(3) Except when medical necessity is documented, lenses larger than size 61 millimeters are not covered.

(4) All Medicaid claim forms submitted for vision materials must be accompanied by a valid copy of the laboratory invoices.

(5) Reimbursement for eyeglasses provided to a recipient under nineteen (19) twenty-one (21) years of age will be limited to a maximum of one (1) pair per year only if the criteria set out in subdivision (7) have been met. The office will provide reimbursement for repairs or replacements of eyeglasses only after receiving documentation that the repair or replacement is necessary due to extenuating circumstances beyond the recipient's control, for example, fire, theft, or automobile accident. The documentation of the extenuating circumstances:

(A) must be maintained in the provider's office; and

(B) shall be subject to postpayment review and audit.

(6) Reimbursement for eyeglasses provided to a recipient nineteen (19) twenty-one (21) years of age or over is limited to a maximum of one (1) pair every two (2) five (5) years if the criteria set out in subdivision (7) have been met. Replacements will only be covered under subdivision (5).

(7) The office shall not provide reimbursement for an initial or subsequent pair of glasses unless the minimum prescription or change meets the following criteria:

(A) For one (1) eye, a minimum initial prescription or, for a subsequent pair of glasses, a change of seventy-five hundredths (.75) diopters for a patient six (6) to forty-two (42) years or of age and fifty-hundredths (.50) diopters prescription or change for a patient over forty-two (42) years of age.

(B) An axis change of at least fifteen (15) degrees.

When provided in accordance with subdivisions (5) and (6), glasses that meet the criteria of this subdivision may be provided without prior authorization.

(8) Safety lenses are covered only for corneal lacerations or other severe intractable ocular or ocular adnexal disease.

(Office of the Secretary of Family and Social Services; 405 IAC 5-23-4; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3343; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA)

Posted: 03/23/2011 by Legislative Services Agency

DIN: 20110323-IR-405100794PRA

Composed: Nov 01,2016 1:07:28AM EDT

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