DAR File No. 28583

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-53

Eyeglasses Services

NOTICE OF PROPOSED RULE

DAR File No.: 28583
Filed: 03/29/2006, 03:24
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to keep expenditures for vision care services within appropriations authorized by the 2006 General Session of the Utah Legislature.

Summary of the rule or change:

In Section R414-53-3, the phrase "except for nonpregnant adult recipients ages 21 and older" is added to exclude that group from eyeglasses services. Also, the word "declares" is changed to "documents" throughout Section R414-53-4, to refer to a medically necessary determination made by a physician or optometrist.

State statutory or constitutional authorization for this rule:

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

Anticipated cost or savings to:

the state budget:

There is an annual savings of $780,900 to the state general fund and $1,877,200 of federal funds.

local governments:

There is no budget impact to local governments because there is no funding from local governments for vision care services.

other persons:

There is an aggregate cost of $2,658,100 to eyeglasses providers and an aggregate cost of $5,316,200 to Medicaid recipients who pay for eyeglasses at an out-of-pocket retail rate.

Compliance costs for affected persons:

There is an average annual cost of $4,567 to a single eyeglasses provider, based on the total number of 582 Medicaid eyeglasses providers and the estimate of one visit per year by a single client. There is also an estimated cost of $225 to an individual Medicaid recipient who must pay for eyeglasses at an out-of-pocket retail rate.

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 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:

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.

R414-53. Eyeglasses Services.

R414-53-1. Introduction and Authority.

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 [C]categorically and [M]medically [N]needy [clients]individuals except for non-pregnant adult recipients ages 21 and older.

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]documents that they are medically necessary. Eyeglasses may not be replaced more often than every two years unless the prescribing physician or optometrist [declares]documents that an earlier replacement [to be]is medically necessary. Circumstances 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]are damaged through client negligence or abuse.

(5) The audiologist or hearing aid provider may provide frames that have hearing aids placed in the earpieces. 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]documents that they are 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 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 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.

(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.

KEY: Medicaid, eyeglasses

Date of Enactment or Last Substantive Amendment: [July 1, 2005]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 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.