DAR File No. 28582

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-52

Optometry Services

NOTICE OF PROPOSED RULE

DAR File No.: 28582
Filed: 03/29/2006, 03:14
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking clarifies eligibility and service coverage for eyeglasses under the Optometry Program, in accordance with appropriations authorized by the 2006 General Session of the Utah Legislature.

Summary of the rule or change:

Section R414-52-3 clarifies that nonpregnant adult recipients ages 21 and older are no longer eligible for eyeglasses. This subsection also removes the reference to definitions of "categorically and medically needy." In Section R414-52-4, the words "and the provision of eyeglasses" are added to the list of optometry services, to clarify that eyeglasses are available to other categorically and medically needy individuals. In Section R414-52-2, the reference to the definition of the term "client" is removed. The title for Section R414-52-1 is changed to "Introduction and Authority." The change in this section also adds a state code citation and amends the federal citation previously listed.

State statutory or constitutional authorization for this rule:

Section 26-18-3 and 42 CFR 440.60 and 440.120(d)

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this rulemaking only clarifies eligibility and service coverage for eyeglasses under the Optometry Program. The companion filing for this rulemaking, Rule R414-53, details the state budget impact through the elimination of vision care services. (DAR NOTE: The proposed amendment to Rule R414-53 is under DAR No. 28583 in this issue.)

local governments:

There is no budget impact to local governments because this rulemaking only clarifies eligibility and service coverage for eyeglasses under the Optometry Program, and there is no funding from local governments for vision care services.

other persons:

There is no budget impact to other persons because this rulemaking only clarifies eligibility and service coverage for eyeglasses under the Optometry Program. The companion filing for this rulemaking, Rule R414-53, details the budget impact to other persons though the elimination of vision care services.

Compliance costs for affected persons:

There are no compliance costs because this rulemaking only clarifies eligibility and service coverage for eyeglasses under the Optometry Program. The companion filing for this rulemaking, Rule R414-53, details the compliance costs for affected persons through the elimination of vision care services.

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

This rule will reduce the number of Medicaid recipients eligible to receive vision services and is necessary to stay within appropriations. 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 or Don Hawley at the above address, by phone at 801-538-6641 or 801-538-6483, by FAX at 801-538-6099 or 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov or dhawley@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:

05/15/2006

This rule may become effective on:

05/16/2006

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

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

R414-52. Optometry Services.

R414-52-1. Introduction and Authority[ and Purpose].

[Optometry services are authorized by 42 CFR , section 440.60, October 1992 edition, which addresses medical services provided by licensed practitioners. ]The Optometry Program provides optometry services to meet the optometry needs of Medicaid clients. This rule is authorized under Utah Code 26-18-3 and governs the services allowed under 42 CFR 440.60.

R414-52-2. Definitions.

[(1) ]The definitions in the Utah Optometry Practice Act, Title 58, Chapter 16a, apply to this rule.[

(2) For the purposes of this rule, "Client" has the same meaning as defined in R414-1-2.]

R414-52-3. Client Eligibility Requirements.

Optometry services are available to [C]categorically and [M]medically [N]needy individuals, except that non-pregnant adult recipients ages 21 and older do not receive eyeglasses under this rule.[Definitions of Categorically and Medically Needy individuals are found in R414-1-2.]

R414-52-4. Service Coverage.

(1) Optometry services include [the ]examination, evaluation, diagnosis[,] and treatment of visual deficiency[;], removal of a foreign body[;], and the provision of eyeglasses.[and ] In addition, Medicaid medical services [open to]performed by physicians [which ]may also be performed by optometrists under the Utah Optometry Practice Act.

(2) The optometrist must document in the patient record that the eye examination is medically necessary.

R414-52-5. Reimbursement.

(1) Fees for services for which the Department will pay optometrists are established from the physician's fees for CPT codes as described in the State Plan, Attachment 4.19-B, Section D Physicians. 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.

(2) 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, optometry

Date of Enactment or Last Substantive Amendment: [January 1, 2004]2006

Notice of Continuation: June 6, 2003

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Craig Devashrayee or Don Hawley at the above address, by phone at 801-538-6641 or 801-538-6483, by FAX at 801-538-6099 or 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov or dhawley@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.