Or. Admin. Code § 410-140-0140 - Vision Coverage
(1) The
Division covers:
(a) Ocular prosthesis (e.g.,
artificial eye) and related services (OAR
410-122-0640).
(b) Reasonable services for diagnosing
conditions, including the initial diagnosis of a condition that is below the
funding line on the Prioritized list. When a diagnosis is established for a
service, treatment, or item that falls below the funding line, the Division may
not cover any other services related to the diagnosis unless the member meets
the comorbidity rules (OAR
410-141-3820(10)
& (11)).
(c) Orthoptic and
pleoptic training or "vision therapy" under EPSDT (refer to Division 410,
Chapter 151) as followed:
(A) When therapy
treatment pairs with a covered diagnosis on the Prioritized List; and
(B) Limited to six (6) sessions per calendar
year (no PA required):
(i) The initial
evaluation is included in the six (6) therapy sessions;
(ii) Additional therapy sessions require PA
(OAR 410-140-0420);
(iii) Providers
shall develop a therapy treatment plan and regimen that shall be taught to the
member, family, foster parents, and caregiver during the therapy treatments. No
extra treatments shall be authorized for teaching;
(iv) Therapy that can be provided by the
member, family, foster parents, and caregiver is not a reimbursable service;
and
(v) All vision therapy services
including the initial evaluation shall be billed to the Division with the
Current Procedural Terminology (CPT) code for orthoptic and pleoptic
training.
(2) Division members are enrolled for covered
health services to be delivered through one of the following means:
(a) Managed Care Entity (MCE) as defined in
OAR 410-120-0000. Payment for all
vision services provided to MCE members by ophthalmologists, optometrists, and
opticians is a matter between the provider and the MCE;
(b) Fee-for-service (FFS):
(A) FFS members are not enrolled in an MCE
and may receive vision services from any Division-enrolled provider that
accepts FFS members subject to limitations and restrictions in the visual
services program rules; and
(B) All
claims must be billed directly to the Division.
(3) When a member has both Medicare and
coverage through the Division, optometrists and ophthalmologists shall bill
Medicare first for Medicare covered services.
(4) When a member has third party liability
(TPL) and coverage through the Division, optometrists and ophthalmologists
shall bill TPL first for TPL covered services.
(5) When an OHP member receives services on a
FFS basis under the Division's rules and has Medicare or TPL coverage:
(a) A provider may order visual materials
from any visual materials supplier; and
(b) The Division does not require PA for
Medicare or TPL covered services.
(6) Coverage for eligible adults (age 21 and
older):
(a) One complete examination and
determination of refractive state is limited to once every 24 months for
non-pregnant members;
(b) One
complete examination and determination of refractive state is limited to once
(1) every 24 months for pregnant members and during the protected post-partum
12-month period (OAR 410-200-0135).
(c) Diagnostic evaluations and medical
examinations are not limited if documentation in the physician's or
optometrist's clinical record justifies the medical need for
diagnosis;
(d) Ophthalmological
intermediate and comprehensive exam services are not limited for allowable
medical diagnosis;
(e) Visual
services for the purpose of prescribing glasses or contact lenses and fitting
fees are as follows:
(A) When determined
necessary during a limited complete examination and determination of refractive
state for pregnant members and during the protected post-partum 12-month period
(OAR 410-200-0135).
(B) Non-pregnant adults are not covered,
except when the member:
(i) Has a medical
diagnosis of aphakia, pseudophakia, congenital aphakia, keratoconus;
or
(ii) Lacks the natural lenses of
the eye due to surgical removal (e.g., cataract extraction) or congenital
absence; or
(iii) Has had a
keratoplasty surgical procedure (e.g., corneal transplant) with limitations
described in OAR 410-140-0160 (Contact Lens
Services and Supplies).
(7) OHP Plus Children (birth through age 20):
(a) All ophthalmological examinations and
vision services, including routine vision exams, fittings, repairs, and
materials are covered when documentation in the clinical record justifies the
medical need;
(b) The standard of
care and expectation is that all comprehensive eye exams for children be
dilated.
(c) With the diagnosis of
Amblyopia, band-aid patches treatment shall be covered with a prescription.
Quantity limit is sixty (60) per thirty (30) days.
(8) Refraction determination is not limited
following a diagnosed medical condition (e.g., multiple sclerosis).
(9) The Division reimburses all covered
surgical procedures as global packages, except when the surgeon codes the
surgical procedure with a modifier indicating surgical procedure only,
excluding post-operative care.
(10)
The Division OHP vision benefit packages:
(a)
For non-pregnant adults (age 21 and older), visual services and materials to
diagnose and correct disorders of refraction and accommodation are covered only
when the member:
(A) Has a covered medical
diagnosis, following cataract surgery or a corneal lens transplant as described
in OAR 410-140-0140; or
(B) Is in their protected post-partum
12-month period (see OAR
410-200-0135);
(b) For pregnant adult people (age
21 and older) other visual services are covered with limitations as described
in these rules;
(c) For children
(birth through age 20): Visual services are covered as described in this rule
and without limitation when documentation in the clinical record justifies the
medical need.
(11)
Post-operative care includes all related follow-up visits and examinations
provided within:
(a) Ninety (90) days
following the date of major surgery; or
(b) Ten (10) days following the date of minor
surgery; and
(c) Claims for
evaluation and management services and ophthalmological examinations billed
within the follow-up period shall be denied.
(12) Provider Error: Neither the contractor
nor the Division shall be responsible for costs, expenses or for any required
rework due to errors by any provider.
Notes
Publications: Publications referenced are available from the agency.] [ Tables referenced are not included in rule text. Click here for PDF copy of table(s)
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.025, 414.065 & 414.075
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