Or. Admin. Code § 410-140-0430 - Limitations and Exclusions

(1) Buying up, as defined in OAR 410-120-1350 is prohibited.

(2) Vision therapy is not covered except under EPSDT when medically necessary and medically appropriate (Refer to Chapter 410, Division 151).

(3) The following ophthalmic materials are not covered and include, but are not limited to:

(a) Glasses with a prescription that is equal to or less than +/-.25 diopters in both eyes;

(b) Two (2) pair of glasses instead of bifocals or trifocals in a single frame;

(c) Hand-held, low vision aids;

(d) Non-spectacle mounted aids;

(e) Single lens spectacle mounted low vision aids;

(f) Telescopic and other compound lens systems, including distance vision telescopic, near vision telescopes, and compound microscopic lens systems;

(g) Extra or spare pairs of glasses;

(h) Anti-reflective lens coating;

(i) U-V lens;

(j) Progressive and blended lenses;

(k) Bifocals and trifocals segments over 28mm including executive;

(l) Aniseikonic lenses;

(m) Sunglasses; and

(n) Frame styles outside of the contract between the Division and contractor based on member preference and are not medically necessary.

(4) 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.

(5) 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

Or. Admin. Code § 410-140-0430

DMAP 127-2024, adopt filed 10/08/2024, effective 10/8/2024

Statutory/Other Authority: ORS 413.042

Statutes/Other Implemented: 414.025, 414.065, 414.591 & 414.631