DAR File No. 27849

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-53

Eyeglasses Services

NOTICE OF PROPOSED RULE

DAR File No.: 27849
Filed: 05/02/2005, 09:52
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to restore eyeglasses services to all categorically and medically needy clients.

Summary of the rule or change:

The title for Section R414-53-1, Authority and Purpose, is changed to "Introduction and Authority." This section is also amended to clarify the statutory authority for the rule. The change to Section R414-53-3, Client Eligibility, deletes language that limits eyeglasses services to categorically and medically needy clients who are ages 20 and younger or who are pregnant. By this deletion, eyeglasses services are restored to all categorically and medically needy clients. Also, language in this section that references definitions for the "categorically needy" and the "medically needy" is deleted.

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3, and 42 CFR 440.120(d)

Anticipated cost or savings to:

the state budget:

There is a total annual cost of $3,702,200 to the state budget as a result of this rulemaking, $1,069,700 in state general funds for the restoration of vision care with a federal match of $2,632,500.

local governments:

There is no budget impact to local governments as a result of this rulemaking because there is no funding from local governments for eyeglasses services.

other persons:

There is an annual increase of $3,702,200 in revenue to eyeglasses providers.

Compliance costs for affected persons:

There is an average annual increase in revenue of $62,749 to a single eyeglasses provider based on the total number of 59 Medicaid eyeglasses providers.

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule restores Medicaid vision services for all categorically and medically needy clients effective July 2005 based on appropriations approved in the 2005 Legislative session. It will have a positive impact on businesses serving Medicaid clients. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

06/14/2005

This rule may become effective on:

06/15/2005

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-53. Eyeglasses Services.

R414-53-1. Introduction and Authority[ and Purpose].

[Eyeglasses are authorized by 42 CFR, 440.120(d), October 1992 edition. ]The Eyeglasses Program provides eyeglasses services to meet the basic vision care needs of Medicaid recipients. This rule is authorized under Utah Code 26-18-3 and governs the services allowed under 42 CFR 440.120(d).

R414-53-2. Definitions.

"Eyeglasses" means lenses, including frames, contact lenses, and other aids to vision that are prescribed by a physician skilled in diseases of the eye or by an optometrist.

R414-53-3. Client Eligibility Requirements.

Eyeglasses are available to Categorically and Medically Needy clients[ who are ages 20 and younger or who are pregnant. Definitions of Categorically and Medically Needy individuals are found in R414-1-2].

R414-53-4. Service Coverage.

(1) Corrective lenses and frames may be provided based on medical need. Medical need includes a change in prescription or replacement as a result of normal lens or frame wear. Frames must be those in which lenses can be replaced readily without having to provide a new frame. Corrective lenses must be suitable for indoor and outdoor use[,] and for day and night use.

(2) Single vision, bifocal, or trifocal lenses, with or without slab-off prism, in clear glass or plastic, may be provided.

(3) Only the least expensive frame practicable for use, either plastic or metal, may be provided.

(4) Replacements for existing lenses or frames may be provided if the prescribing physician or optometrist declares them to be medically necessary. Eyeglasses may not be replaced more often than every two years unless the prescribing physician or optometrist declares an earlier replacement to be medically necessary. Circumstances [which would]that warrant providing new eyeglasses or contact lenses[,] are a diopter change of .75 or more, or disease or damage to the eye. Eyeglasses or contact lenses may not be replaced if they were damaged through client negligence or abuse.

(5) [Frames which have hearing aids placed in the earpieces may be provided by t]The audiologist or hearing aid provider may provide frames that have hearing aids placed in the earpieces. [Lenses for these frames must be dispensed by t]The prescribing physician or optometrist must dispense the lenses for these frames.

(6) The following services may be provided if the prescribing physician or optometrist declares them to be medically necessary:

(a) Contact lenses;

(b) Soft contact lenses;

(c) Gas permeable contact lenses;

(d) Tints for eyeglasses or contact lenses where diseases or conditions are present [which]that render the client unusually light-sensitive;

(e) Low vision aids.

(7) The following services are not provided:

(a) Additional eyeglasses such as reading glasses, distance glasses, or a "spare";

(b) Extended wear contact lenses or disposable contact lenses.

R414-53-5. Reimbursement.

(1) The Department pays for lenses and standard frames on a fee-for-service basis, based on CPT codes as described in the State Plan, Attachment 4.19-B.

(2) The Department pays the lower of the amount billed [and]or the rate on the schedule. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private-pay patients.

([2]3) Fee schedules were initially established after consultation with provider representatives. Adjustments to the schedule are made in accordance with appropriations and to produce efficient and effective services.[

(3) The Department pays the lower of the amount billed and the rate on the schedule. A provider shall not charge the Department a fee that exceeds the provider's usual and customary charges for the provider's private-pay patients.]

KEY: Medicaid, eyeglasses

[January 28, 2004]2005

Notice of Continuation June 6, 2003

26-1-5

26-18-3

ADDITIONAL INFORMATION

PLEASE NOTE:

• Text to be deleted is struck through and surrounded by brackets (e.g., [example]). Text to be added is underlined (e.g., example). Some browsers may not depict some or any of these attributes on the screen or when the document is printed.
• Please see the DISCLAIMER regarding information available from state web pages.

For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.