EPSDT Eyeglass Replacement and Repair Coverage
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Clarifies that eyeglasses and related repair/replacement for members under age 21 are covered under EPSDT when medically necessary, and directs providers to update communications and obtain member financial agreements for non-covered upgrades. Affects vision providers and dispensers contracting with the plan.
No material clinical or coverage changes in this revision.
Coverage Criteria
EPSDT Eyeglass Replacement and Repair Coverage
Covered when ALL of the following are met
Includes loss, breakage, change in refraction, and special lens additions; no waiting for next scheduled EPSDT well-child visit is required.
If a member chooses an upgrade or feature that is not covered by AHCCCS, the provider may offer that upgrade only after the member has provided a signed advance financial responsibility agreement. The agreement must be signed in advance, include a description of the upgrade and an approximate cost, and the provider must obtain approval from the health plan before collecting payment. Failure to obtain a signed agreement prior to charging the member may violate member billing rules (see AAC R9-22-701).
Under EPSDT, AHCCCS is required to cover services for members under age 21 that are medically necessary to "correct or ameliorate" defects, conditions, or illnesses. Services that are experimental are not required to be covered under EPSDT and therefore may be excluded from mandatory coverage.
Provider Actions and Requirements
Prior Authorization Not Required for Timing of Replacement
Prior authorization is not required for timing of eyeglass replacement or repair for EPSDT members (those under 21). Members do not need to wait for their next scheduled EPSDT well-child visit to receive replacement or repair when medically necessary to correct or ameliorate a vision condition.
Obtain Signed Advance Member Agreement for Non‑Covered Upgrades
If a member elects any upgrade or item that is not covered by AHCCCS, the provider must obtain a signed member financial responsibility agreement in advance that documents the member's informed acceptance of financial responsibility. The agreement must describe the non-covered upgrade and provide an approximate cost. Do not collect payment from the member for non-covered upgrades until the signed agreement is obtained and any required communication or approval from the health plan has occurred.
- Member agreement must be obtained in advance of charging the member
- Agreement must describe the non-covered upgrade and give an approximate cost
- Providers should await any required prior communication/approval from the health plan before collecting payment
Risk of Policy Violation if Agreement Not Obtained
Failure to obtain a signed member financial responsibility agreement prior to charging the member for non-AHCCCS-covered upgrades may violate policy and applicable billing rules. Providers are discouraged from 'upselling' or promoting warranties/insurance for EPSDT members; members are not required to agree to upgrades.
- Do not promote or pressure members into purchasing non-covered upgrades, warranties, or insurance
- Ensure member understanding and voluntary acceptance before obtaining signature
Background
EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) requires AHCCCS to cover, for members under age 21, medically necessary services that correct or ameliorate conditions discovered during vision screenings. This coverage explicitly includes eyeglasses and related repair or replacement for loss, breakage, or change in refraction, including special lens additions, and there are no restrictions on replacement or repair when medically necessary. Members do not need to wait for their next scheduled EPSDT well-child visit to receive eyeglass replacement or repair.
Definitions
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