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

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 a more expensive frame is medically necessary. Situations where a more expensive frame may be indicated as medically necessary 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 documentation supporting a determination that said frames are medically necessary. (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. (E) Velvet lite. (3) Except when documented as medically necessary, 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 member under 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 member'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 member twenty-one (21) years of age or over is limited to a maximum of one (1) pair every 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 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.