Ophthalmology Services

The MassHealth agency pays for ophthalmic materials in accordance with the vision care regulations at 130 CMR 402.000: Vision Care. The MassHealth agency pays for eye examinations subject to the following limitations. (A) Comprehensive Eye Examinations. (1) The MassHealth agency does not pay for a comprehensive eye examination if the service has been provided (a) within the preceding 12 months, for a member under 21 years of age; or (b) within the preceding 24 months, for a member 21 years of age or older. (2) The restrictions at 130 CMR 433.425(A)(1) do not apply if one of the following complaints or conditions is documented in the member’s medical record: (a) blurred vision; (b) evidence of headaches; (c) systemic diseases, such as diabetes, hyperthyroidism, or HIV; (d) cataracts; (e) pain; (f) redness; or (g) infection. (B) Consultation Service. The MassHealth agency pays for a consultation service only if it is provided independently of a comprehensive eye examination. (C) Screening Services. The MassHealth agency does not pay for a screening service if two screening services have been furnished to the member within the preceding 12 months. 4 Program Regulations (D) Comprehensive Eye Examinations and Screening Services. A comprehensive eye examination includes a screening service. If the provider performs both a screening service and a comprehensive eye examination for the same member, the MassHealth agency pays for only the comprehensive eye exam. (E) Tonometry. The MassHealth agency does not pay for a tonometry as a separate service when it is performed as part of a comprehensive eye examination, consultation, or 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.