Optical Benefits and Limitations—MO HealthNet Program

PURPOSE: This rule establishes the basis for administering the Optical Program under the MO HealthNet program, including the designation of professional persons who may perform optical services; services which are covered, noncovered, and limitations within the program; and the method of reimbursement. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. The Department of Social Services, MO HealthNet Division shall administer the Optical Program. The Department of Social Services, MO HealthNet Division shall determine, and include in the Optical Provider manual, the optical services covered and not covered, the program limitations, and the maximum allowable fees for all covered services. The Optical Provider manual is incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at http://manuals.momed.com/collections/collection_opt/print.pdf November 24, 2020. This rule does not incorporate any subsequent amendment or additions. Services covered shall include only those which are clearly shown to be medically necessary. (2) Participants Eligible. Any participant who is eligible for MO HealthNet benefits as determined by the Family Support Division and who is found to be in need of optical services as described in this regulation subject to the limitations set forth in subsections (7)(A)–(X). (3) Provider Participation. To be eligible for participation in the MO HealthNet Optical Program, a provider must meet the criteria specified for his/her profession as follows: (A) An optometrist must be a duly licensed Doctor of Optometry (OD) to participate in the MO HealthNet program, must be licensed in accordance with the licensing provisions of the state in which s/he practices, and must have a current MO HealthNet participation agreement and provider number; (B) A physician must be a duly licensed Doctor of Medicine (MD) or Doctor of Osteopathy (DO) to participate in the MO HealthNet program, must be licensed in accordance with the licensing provisions of the state in which s/he practices, and must have a current MO HealthNet participation agreement and provider number; (C) A clinic can participate in the Optical Program if it has a current MO HealthNet Program clinic number. In addition to the clinic number, each of the performing optometrists must have an effective participation agreement and MO HealthNet program provider number. Reimbursement may be made to the clinic for all covered services provided at the clinic; and (D) An optician, optical dispenser, or manufacturer of prosthetic eyes must have a current MO HealthNet participation agreement and provider number. (4) Types of Service Reimbursed by the MO HealthNet Program for Each Profession. (A) Optometrist or Clinic. 1. Eye examinations. 2. Refractions. 3. Eyeglasses. 4. Prosthetic eyes. 5. Special ophthalmological services. (B) Opticians or Optical Dispensers. 1. Eyeglasses. 2. Prosthetic eyes. (C) Manufacturers of Prosthetic Eyes— Prosthetic Eyes. (D) Physicians (MD or DO). 1. Eye examinations. 2. Refractions. 3. Eyeglasses (Must be enrolled as an Optical provider). 4. Prosthetic eyes (Must be enrolled as an Optical provider). 5. Special ophthalmological services. (5) Reimbursement. MO HealthNet reimbursement will be the lower of the provider’s usual and customary charge to the general public or the MO HealthNet allowable amount. (6) Covered Services. (A) Complete or limited eye examination. (B) Eye refraction. (C) Eyeglasses. (D) Frames. (E) Temple. (F) Lenses, single vision. (G) Lenses, bifocal. (H) Lenses, trifocal. (I) Lenses, cataract. (J) Special frames. (K) Special lenses. (L) Miscellaneous repairs. (M) Scleral cover shell, stock, or custom. (N) Prosthetic eye, plastic, or custom. (O) Prosthetic eye, refitting. (P) Prosthetic eye check/polishing/cleaning. (Q) Rose I and Rose II tints. (R) Photochromatic lenses. (S) Orthoptic and/or pleoptic training, with continuing optometric direction and evaluation (visual therapy/training). (T) Fitting of contact lens for treatment of disease, including supply of lens (therapeutic bandage lens). (U) Visual field examination with optometric diagnostic evaluation; tangent screen, autoplot, or equivalent. (V) Electro-oculography, with medical diagnostic evaluation. (W) Visually evoked potential (response) study, with medical diagnostic evaluation. (X) Quantitative perimetry, for example, several isopters on Goldmann perimeter or equivalent. (Y) Static and kinetic perimetry or equivalent. (Z) Serial tonometry with optometric diagnostic evaluation (separate procedure), one (1) or more sessions, same day. (AA) Tonography with optometric diagnostic evaluation, recording indentation tonometer method or perilimbal suction method. (BB) Color vision examination, extended, for example, anomaloscope or equivalent. (CC) Dark adaptation examination, with optometric diagnostic evaluation. (7) Program Limitations. (A) Optical Program services require precertification. Pre-certification serves as a utilization management tool, allowing payment for services that are medically necessary, appropriate, and cost effective without compromising the quality of care to participants. An enrolled optical provider must initiate requests for pre-certification and MO HealthNet must issue approval before delivery of service. The pre-certification medical criteria can be found in the Optical Provider Manual identified in section (1) of this rule. (B) One (1) comprehensive or one (1) limited eye examination is allowed per two (2) years (within a twenty-four- (24-) month period of time) under the MO HealthNet program. Eligible children, pregnant women, individuals residing in a nursing home, and blind persons are allowed one (1) comprehensive or one (1) limited eye examination per year (within a twelve- (12-) month period of time) under the MO HealthNet program. Payment for a comprehensive eye examination will be made only if six (6) or more of the following procedures have been performed: 1. Refraction far point and near point; 2. Case history; 3. Visual acuity testing; 4. External eye examination; 5. Pupillary reflexes; 6. Ophthalmoscopy; 7. Ocular motility testing; 8. Binocular coordination; 9. Vision fields; 10. Biomicroscopy (slit lamp); 11. Tonometry; 12. Color vision; and 13. Depth perception. (C) If fewer than six (6) of these are performed, a limited examination must be billed. (D) Eligible children, pregnant women, individuals residing in a nursing home, and blind persons may be allowed additional eye examinations during the year (within a twelve- (12-) month period of time) if medically necessary (that is, cataract examination, prescription change of 0.50 diopters or greater). (E) Eyeglasses are covered by the MO HealthNet program for MO HealthNet eligible participants when the prescription is at least 0.75 diopters for one (1) eye or 0.75 diopters for each eye. (F) Only one (1) pair of eyeglasses is allowed every two (2) years (within any twenty-four- (24-) month period of time) for MO HealthNet eligible participants. (G) The original eyeglass prescription and laboratory invoices listing costs for optical materials, lenses, and/or frames provided; and the charge for grinding, edging, or assembling of glasses must be kept on file by the provider for six (6) years and furnished to the MO HealthNet Division or its representative upon request. (H) Special frames are covered under the MO HealthNet program if they are required for medical reasons. Special frames may be authorized if the patient requires special lenses (plus or minus 4.00 diopters for one (1) eye or plus or minus 4.00 diopters for each eye and are extra thick or heavy), the structure of the patient’s face requires special frames (a very large face, wide-set eyes), or the patient needs glasses with pads because of nose surgery. (I) Special lenses are covered under the MO HealthNet program if they are medically justified and the prescription is plus or minus 4.00 diopters for one (1) eye or plus or minus 4.00 diopters for each eye, cataract lenses, or special bifocal lenses (for example, plastic Executive lenses). (J) Plastic lenses may be dispensed under the MO HealthNet program. Reimbursement will be at the same rate as comparable glass lenses. Additional payment will be allowed for plastic lenses that meet the definition of special lenses and are medically justified. (K) Photochromatic lenses are covered only if medically necessary. (L) Tinted lenses (Rose I and Rose II) are covered if medically necessary. (M) Replacement of optical materials and repairs in excess of program limitations may be covered if medically necessary, or required for employment training, or educational purposes, as follows: 1. Replacement of complete eyeglasses (frames and lenses). A. Lenses and frames broken (participant must show provider the broken glasses or the MO HealthNet program will not pay for the glasses). B. Lost. C. Destroyed. D. Stolen. E. Repair of existing glasses would exceed the MO HealthNet allowable amount for new frames and lenses; 2. Lenses—if medically necessary. A. Scratched. B. Broken. C. Prescription change of at least 0.50 diopters or greater; or 3. Frames—Temples, fronts, or both broken and repair would exceed the MO HealthNet allowable amount for new frames. (N) Repair of frames or replacement of parts of frames (temples) are covered as follows: 1. The cost of the repairs do not exceed the MO HealthNet allowable amount for new frames; and 2. Repair would provide a serviceable frame for the participant. (O) Temples may never be billed in addition to complete new eyeglasses and new frames. (P) An eye refraction may be reimbursed in addition to a comprehensive or limited eye examination. Because an eye refraction is not covered by Medicare but is covered by MO HealthNet, providers may bill MO HealthNet for an eye refraction when the patient has Medicare and MO HealthNet coverage. (Q) Eyeglasses may be covered by MO HealthNet for a prescription of less than 0.75 diopters if medically necessary. Eyeglasses less than 0.75 diopters will be approved for the following reasons: 1. Child age twenty (20) and under who requires glasses for school performances; 2. Visual acuity 20/40 or less; or 3. Protective eyewear for participants with sight in only one (1) eye. (R) Any warranties extended by optical companies for optical materials to private-pay patients must also apply to those same materials dispensed to MO HealthNet participants. (S) The MO HealthNet program allows one (1) prosthetic eye per eye (one (1) left and one (1) right) within a five- (5-) year period. If the prosthetic eye is lost, destroyed, cracked, or deteriorated, payment will be allowed for replacement. (T) Optometrists may be reimbursed for visual therapy training when there is a prognosis for substantial improvement or correction of an ocular or vision condition. These conditions include amblyopia, eccentric (nonfoveal) monocular fixation, suppression, inadequate motor or sensory fusion, and strabismus (squint). The number of training sessions is limited to one (1) per day, two (2) per week, and a maximum of twenty (20) sessions. If the patient shows significant improvement after the initial twenty (20) sessions and the optometrist feels that further progress could be made, additional training sessions not to exceed a total of forty (40) sessions may be provided. (U) Fitting of contact lens for treatment of disease, including supply of lens (therapeutic bandage lens) is covered if it is prescribed by a physician (MD or DO) or optometrist (OD) as a bandage to cover a diseased condition of the eye, such as a bandage over an abrasion of the skin. The lens must be plain with no corrective power. Diagnosis for which the lens should be reimbursed are Bullous Kerotopathy, Corneal Ulcers, Ocular Pemphigoid, and other corneal exposure problems. (V) Visual field examination with optometric diagnosis evaluation, tangent screen autoplot, or equivalent is covered when performed by an optometrist. (W) Quantitative perimetry, for example, several isopters on Goldmann perimeter, or equivalent is covered. (X) Serial tonometry with optometric diagnostic evaluation (separate procedure), one (1) or more sessions on the same day is covered when performed by an optometrist. Routine tonometry is included in the reimbursement for a comprehensive examination and cannot be billed separately. (8) Noncovered Services. (A) Eyeglass frames with hearing aids attached. (B) Optical services or materials provided to a participant who was not eligible on the date the service was provided or the optical materials were delivered to the patient. (C) Sales or use tax on optical materials (the participant is not responsible for and may not be billed for such taxes). (D) Contact lenses other than for medical purposes as described above in subsection (7)(T). (E) Sunglasses. (F) Lenses exceeding 65 mm in diameter or frames for such lenses. (G) Temporary lenses for cataract lenses. (H) Eyeglass cases. (I) Monicals. (J) Magnifiers. (K) Eye medications. (L) Repair of old frames if the repair exceeds the cost of new frames. (M) Replacement of optical materials resulting from patient abuse. (N) Optical materials which are not medically necessary. (O) Nose pads. (P) Eyeglass adjustments. (Q) Optical materials not meeting MO HealthNet Division standards. (R) Lenses or frames supplied incorrectly to the provider by the supplier or manufacturer. (S) Replacement of lenses, complete eyeglasses, frames, or prosthetic eyes supplied incorrectly to participant by optical provider. (T) Optical materials in excess of those authorized within the benefit period. (9) General Regulations. This rule shall not encompass all of the general regulations of the MO HealthNet program. These regulations, however, shall be in effect for the optical section of the overall program. (10) Records Retention. MO HealthNet may impose sanctions against a provider for failure to make available or disclose to the MO HealthNet agency or its authorized agents, all records relating to services provided to MO HealthNet participants or records related to MO HealthNet payments, whether or not the records are comingled with non-MO HealthNet records, in compliance with 13 CSR 703.030. Providers must retain these records for six (6) years from the date of service. Fiscal and medical records must coincide with, and fully document, services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2021.* This rule was previously filed as 13 CSR 40-81.170. Emergency rule filed April 10, 1981, effective April 20, 1981, expired July 10, 1981. Original rule filed April 10, 1981, effective July 11, 1981. Emergency amendment filed June 27, 2002, effective July 7, 2002, terminated Feb. 23, 2003. Amended: Filed July 15, 2002, effective Feb. 28, 2003. Amended: Filed March 3, 2003, effective Oct. 30, 2003. Emergency amendment filed Aug. 11, 2005, effective Sept. 1, 2005, expired Feb. 27, 2006. Amended: Filed June 1, 2005, effective Nov. 30, 2005. Emergency amendment filed June 15, 2006 effective July 1, 2006, expired Dec. 28, 2006. Amended: Filed May 15, 2006, effective Nov. 30, 2006. Amended: Filed Aug. 17, 2009, effective Feb. 28, 2010. Amended: Filed Oct. 10, 2013, effective April 30, 2014. Amended: Filed March 5, 2021, effective Oct. 30, 2021. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.