13 CSR 70-40.010 - Optical Benefits and Limitations-MO HealthNet Program
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/col-lection_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
Health-Net 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 (non-foveal) 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
Kero-topathy, 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
Health-Net records, in compliance with
13 CSR
70-3.030. 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.
Notes
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