Service Limitations: Replacement Eyeglasses

(A) Broken Eyeglasses. The MassHealth agency pays for the repair of broken eyeglasses, including the replacement of broken parts, subject to the following limitations. 1) If a broken frame can be repaired and replacement parts are available from the optical supplier, the MassHealth agency pays for repair rather than replacement. If replacement parts are not available from the optical supplier, the MassHealth agency pays for an entire replacement frame. (2) Except for members younger than 21 years old, the MassHealth agency does not pay without prior authorization for the replacement of broken frames and lenses if a repair of either broken frames or lenses was furnished within the preceding 24 months. (3) Dispensing practitioners must order replacement eyeglass frames, lenses, and repair parts from the optical supplier. Dispensing practitioners must use the order form to obtain replacement parts. (4) Payment for dispensing replacement lenses may be claimed under the appropriate service code (see Subchapter 6 of the Vision Care Manual) where applicable for the lens being dispensed, but only if each broken lens meets the minimum power criteria for an initial pair of eyeglasses as described in 130 CMR 402.427(A). (B) Lost Eyeglasses (Child). The MassHealth agency pays for the replacement of lost or stolen eyeglasses within the preceding 12 months of the previous eyeglass dispensing for members younger than 21 years old without PA. (C) Lost Eyeglasses (Adult). The MassHealth agency pays for one replacement of lost or stolen eyeglasses within the preceding 24 months for member 21 years of age or older without PA. Subsequent replacement of a pair of lost or stolen eyeglasses within the 24-month period requires prior authorization. (D) Prescription Changes. The MassHealth agency pays for new eyeglasses with a different prescription prior to the standard frequency service limitation at 130 CMR 402.427, only if there is a change from the current prescription of at least +.50D sphere or cylinder; or an axis change of at least 3º for a +1.00D cylinder or over, 5º for a +.75D cylinder, or 10º for a +.50D cylinder. Prior authorization is not required. (E) Plano. MassHealth pays for a plano lens (no correction required) for a member who is Monocular. Prior authorization is not required. (F) Appropriate Service Codes. The appropriate service codes (see Subchapter 6 of the Vision Care Manual) must be used when submitting claims for dispensing replacement frames or parts of frames.