CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Medicaid Optometry Services

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This rule governs District of Columbia Medicaid reimbursement for optometry services related to vision and vision disorders, including eye exams, eyeglasses, other vision aids, and therapeutic drugs. It establishes coverage criteria, frequency limits, prior authorization requirements, and provider qualifications for Medicaid beneficiaries.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyMedicaid Optometry Services

Policy CodePolicy N/A

Change TypeNew section adopted

Effective DateJanuary 22, 2016

Next Review DateN/A

Key ActionObtain prior authorization before providing additional optometry services or repairing or replacing covered vision devices.

SourceLink

POLICY UPDATE CHANGES

A new Section 965 establishing coverage and limitations for Medicaid optometry services was adopted.

1 / 24 moStandard eyeglass limit

1 / 12 moUnder-21 eyeglass limit

2 pathwaysAdult exam pathways

PA requiredRepairs and replacements

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CurrentDistrict of Columbia Department of Health Care FinancePolicy N/A

Medicaid Optometry Services

Customize your policy alerts

Sign up for all District of Columbia Department of Health Care Finance policy alerts

Know when District of Columbia Department of Health Care Finance releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyMedicaid Optometry Services

Policy CodePolicy N/A

Change TypeNew section adopted

Effective DateJanuary 22, 2016

Next Review DateN/A

Key ActionObtain prior authorization before providing additional optometry services or repairing or replacing covered vision devices.

SourceLink

POLICY UPDATE CHANGES

A new Section 965 establishing coverage and limitations for Medicaid optometry services was adopted.

1 / 24 moStandard eyeglass limit

1 / 12 moUnder-21 eyeglass limit

2 pathwaysAdult exam pathways

PA requiredRepairs and replacements

EnrolledProvider status

Covered Optometry Services and Limits

Covered optometry services

Eligible for Medicaid reimbursement when ALL of the following are met:

Covered optometry service

Service requirements
- The service is related to vision or vision disorders.
- The service is obtained for the purpose of diagnosis or treatment.
- The service is an eligible optometry service, including lenses, frames, other aids to vision, or therapeutic drugs.

Eye exams for beneficiaries over 21

Covered for beneficiaries over 21 when ALL of the following are met and at least one qualifying condition is present:

Adult eye exam

The beneficiary is over 21 years of age.Over 21 years of age
The eye exam is medically necessary.
ONE qualifying condition
- The exam is required to monitor a chronic condition that could harm the beneficiary's vision.
- The beneficiary has an acute condition that, if left untreated, may cause permanent or chronic damage to the eye.

Eye exams for beneficiaries from birth through 21

Covered under Early and Periodic Screening, Diagnosis, and Treatment requirements:

Pediatric eye exam

The beneficiary is from birth through 21 years of age.Birth through 21 years of age
Coverage is provided under Early and Periodic Screening, Diagnosis, and Treatment program requirements, as set forth in 42 C.F.R. Section 440.40(b).

Eyeglasses and frequency limits

Eyeglasses are covered when the applicable frequency limit or a qualifying exception is met. The limits apply to new eyeglasses, duplicates, and prescription changes.

Frequency limit or qualifying exception

For beneficiaries generally, reimbursement is limited to one complete pair of eyeglasses in a 24-month period.1 complete pair / 24 months
For beneficiaries under 21, reimbursement is limited to one complete pair of eyeglasses in a 12-month period.1 complete pair / 12 months
ONE qualifying exception
- The beneficiary is under 21 years of age.

Repairs and replacements

Covered only when ALL of the following requirements are met:

Repair or replacement coverage

The repair or replacement is for a listed item: eyeglasses, contact lenses, glass lenses, ultraviolet lenses, prosthetic eyes, polycarbonate or equivalent lenses, tinted lenses, or photochromatic lenses.
DHCF has provided prior authorization.
Written documentation establishes that the repair or replacement is medically necessary.
For repairs or replacements of eyeglasses, the service was ordered in writing by an optometrist licensed under the District of Columbia Health Occupations Revision Act.

Provider eligibility and dispensing procedures

Reimbursement requires ALL of the following:

Provider eligibility and dispensing compliance

The optometrist is screened and enrolled as a District Medicaid program provider pursuant to Chapter 94 of Title 29 of the District of Columbia Municipal Regulations.
The optometrist adheres to dispensing procedures in the Vision Billing Manual published on the Department of Health Care Finance's Provider website at www.dc-medicaid.com.

Frequency Limits and Prescription Thresholds

Standard eyeglass frequency

Coverage limit1 complete pair of eyeglasses

Frequency period24 months

Applies toMedicaid beneficiaries generally, unless an applicable exception is met

Eyeglass frequency for beneficiaries under 21

Eligible beneficiariesBeneficiaries under 21 years of age

Coverage limit1 complete pair of eyeglasses

Frequency period12 months

Authorization, Documentation, and Billing Requirements

Prior Authorization

Additional Services Require Prior Authorization

Medicaid reimbursement is limited to the specific optometry services listed in Section 965 and any additional optometry services identified by DHCF or its agent that have received prior authorization.

Confirm that any additional service identified at www.dc-medicaid.com has DHCF or agent prior authorization before providing it for reimbursement.

Prior Authorization

Prior Authorization Required for Repairs and Replacements

Repairs or replacements of eyeglasses, contact lenses, glass lenses, ultraviolet lenses, prosthetic eyes, polycarbonate or equivalent lenses, tinted lenses, and photochromatic lenses require prior authorization from DHCF.

Obtain prior authorization before billing repairs or replacements for any listed eyewear or vision device.

Policy Scope

This policy covers optometry services related to vision and vision disorders when obtained for diagnosis or treatment. Covered services include corrective lenses, frames, contact lenses and other aids to vision, as well as therapeutic drugs, when provided in accordance with applicable federal requirements.

Key Terms

Eyeglasses

LensesLenses prescribed as aids to vision

Frames and contact lensesIncludes frames and contact lenses

Other vision aidsIncludes other aids to vision

Authorized prescribersA physician skilled in diseases of the eye or an optometrist

Policy Summary

PayerDistrict of Columbia Department of Health Care Finance

PolicyMedicaid Optometry Services

Policy CodePolicy N/A

Change TypeNew section adopted

Effective DateJanuary 22, 2016

Next Review DateN/A

Key ActionObtain prior authorization before providing additional optometry services or repairing or replacing covered vision devices.

SourceLink

On This Page

The new prescription represents a change of at least +/- 0.50 diopters from the prior prescription.

At least +/- 0.50 diopters

The prescription represents a change from the prior prescription of at least +0.75 sphere or -0.50 sphere, 0.50 cylinder, 1/2 prism diopter vertical, or 3 prism diopter lateral.

A major change in visual acuity has been documented by an optometrist licensed under the District of Columbia Health Occupations Revision Act, and the new lenses cannot be accommodated by the beneficiary's existing eyeglasses.

The frames or lenses have been lost, broken beyond repair, or scratched to the extent that visual acuity is compromised, as determined by the dispensing provider.

Prescription-change exception

Qualifying changeAt least +/- 0.50 diopters

ComparisonChange from the prior prescription

EffectMay qualify for an exception to the eyeglass frequency limit

Alternative prescription-change measurements

Sphere changeAt least +0.75 sphere or -0.50 sphere

Cylinder change0.50 cylinder

Vertical prism change1/2 prism diopter vertical

Lateral prism change3 prism diopters lateral

Documentation Required

Document Medical Necessity for Authorization

DHCF may authorize reimbursement for a repair or replacement only after receiving written documentation establishing that the service is medically necessary.

Submit written medical-necessity documentation with the prior-authorization request.
Claims may be denied when the required authorization or supporting documentation is absent.

Unsupported block type: documentation

Documentation Required

Document the Prescription-Change Exception

The one-pair eyeglass limit may be exceeded when the new prescription reflects a qualifying change from the prior prescription.

Document a change of at least +/- 0.50 diopters from the prior prescription.
A qualifying change may also include at least +0.75 sphere, -0.50 sphere, 0.50 cylinder, 1/2 prism diopter vertical, or 3 prism diopters lateral.

Documentation Required

Document a Visual-Acuity Change

A replacement pair may be covered when there has been a major change in visual acuity, documented by an optometrist licensed under the District of Columbia Health Occupations Revision Act, and the new lenses cannot be accommodated by the beneficiary’s existing eyeglasses.

Ensure the licensed optometrist documents the major visual-acuity change and why the existing eyeglasses cannot accommodate the new lenses.

Documentation Required

Document Lost or Damaged Eyewear

The one-pair limit may be exceeded when frames or lenses are lost, broken beyond repair, or scratched enough to compromise visual acuity, as determined by the dispensing provider.

Document the condition of the eyewear and the dispensing provider’s determination supporting replacement.

Documentation Required

Written Medical-Necessity Records Required

When seeking prior authorization for a repair or replacement, submit written documentation showing that the service is medically necessary. DHCF may authorize reimbursement only after receiving the required documentation.

Written medical-necessity records are required for repair or replacement authorization.

Documentation Required

Written Optometrist Order Required

Repairs or replacements of eyeglasses covered by Subsection 965.8 are reimbursable only when ordered in writing by an optometrist licensed under the District of Columbia Health Occupations Revision Act, as amended.

Obtain and retain the written order from the properly licensed optometrist.

Denial Risk

Unauthorized Services Are Not Reimbursable

Services outside Section 965 or DHCF-listed additional services are not reimbursable unless they meet the applicable prior-authorization requirements.

Do not bill services that are neither listed in Section 965 nor identified by DHCF and authorized by DHCF or its agent.

Denial Risk

Adult Exam Without a Qualifying Condition

An eye exam for a beneficiary over 21 is not reimbursable unless it is medically necessary and tied to a qualifying chronic condition that could harm vision or an acute condition that could cause permanent or chronic eye damage if untreated.

Claims lacking documentation of the qualifying condition may be denied.

Denial Risk

Eyeglass Frequency Limits Apply

Eyeglasses are generally limited to one complete pair in a 24-month period for beneficiaries 21 and older, and one complete pair in a 12-month period for beneficiaries under 21. The limit applies to new prescriptions, duplicates, and prescription changes.

Document a qualifying exception before billing beyond the applicable frequency limit, including an eligible prescription change, major visual-acuity change, or lost or damaged eyewear.

Denial Risk

Authorization or Documentation Gaps Risk Denial

Claims for repairs or replacements may be denied without DHCF prior authorization, written medical-necessity documentation, and, for eyeglass repairs or replacements, a written order from a properly licensed optometrist.

Verify that all authorization and supporting records are complete before submitting the claim.

Billing Rule

Provider Enrollment and Dispensing Requirements

Optometry services are reimbursable only when provided by an optometrist screened and enrolled as a District Medicaid program provider under Chapter 94 of Title 29 DCMR and dispensed in accordance with the Vision Billing Manual.

Use a screened and enrolled District Medicaid provider.
Follow dispensing procedures in the Vision Billing Manual at www.dc-medicaid.com.