Service Limitations: Eye Examinations

(A)(1) The MassHealth agency does not pay for a comprehensive eye examination in an optometrist's office or a visual analysis in a home or nursing facility if a comprehensive eye examination or a visual analysis has been furnished: (a) within the preceding 12 months, for a member younger than 21 years old; or (b) within the preceding 24 months, for a member 21 years of age or older. (2) These restrictions do not apply if there is a referral from the member's physician or if one of the following complaints or conditions is documented in the member's record: (a) blurred vision; (b) evidence of headaches; (c) systemic diseases such as diabetes, hyperthyroidism, or HIV; (d) cataracts; (e) eye pain; (f) eye redness; (g) eye infection; (h) double vision; or (i) members receiving long-term therapeutic drugs which may cause ocular side effects. (B) The MassHealth agency pays for a consultation service only if it is provided independently of a comprehensive eye examination. (C) The MassHealth agency does not pay for more than two screening services per 12-month period. (D) A comprehensive eye examination includes a screening service. The provider cannot bill separately for both a screening service and a comprehensive eye examination for the same member. The MassHealth agency pays for only the comprehensive eye exam. (E) The MassHealth agency does not pay for a tonometry as a separate service when it is performed as part of a comprehensive eye examination, a consultation, or a screening service. When a tonometry is performed as a separate service to monitor a member who has glaucoma, the provider must use the appropriate service code (see Subchapter 6 of the Vision Care Manual).