New Mexico Register / Volume XIV, Number 22 / November 26, 2003

 

 

This is an amendment to 8.310.6 NMAC, Sections 10 through 15, which will be effective on December 1, 2003.  The Medical Assistance Division amended the sections to show that Medicaid now covers only one routine eye exam and one set of corrective lenses (including contact lenses) for an adult in a twelve-month period, unless an ophthalmologist or optometrist recommends a change in prescription due to a medical condition affecting vision.  Also, this amendment provides that Medicaid will cover one frame for corrective lenses for an adult in a twenty-four month period.  This rule was also renumbered and reformatted from 8 NMAC 4.MAD.715 to comply with NMAC requirements.

 

8.310.6.10             ELIGIBLE PROVIDERS:

                A.            Upon approval of New Mexico medical assistance program provider participation agreements by the New Mexico medical assistance division (MAD), the following providers are eligible to be reimbursed for providing vision services:

                    (1)     individuals licensed to practice [ophthalmology or optometry] medicine in New Mexico, who limit their practice to ophthalmology (ophthalmologists) and the groups, corporations, and professional associations they form; and

                    (2)     individuals licensed [as opticians; opticians are eligible to participate as providers of eye glasses, contact lenses, supplies, and other materials] to practice optometry in New Mexico and the groups, corporations, and professional associations they form;

                    (3)     individual licensed as optician; opticians are eligible to participate as providers of eyeglasses, contact lenses, supplies, and other vision related materials; and

                    (4)     IHS or tribal facilities operating under Public Law 93-638.

                B.            Once enrolled, providers receive a packet of information, including medicaid program policies, billing instructions, utilization review instructions, and other pertinent [material] materials from MAD.  Providers are responsible for ensuring that they have received these materials and for updating them as new materials are received from MAD.

[2/1/95; 8.310.6.10 NMAC - Rn, 8 NMAC 4.MAD.715.1 & A, 12/1/03]

 

8.310.6.11             PROVIDER RESPONSIBILITIES:

                A.            Providers who furnish services to medicaid recipients must comply with all specified medicaid participation requirements.  See 8.302.1 NMAC, General Provider Policies.

                B.            Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine if medicaid recipients have other health insurance.

                C.            Providers must maintain records [which] that are sufficient to fully disclose the extent and nature of the services provided to recipients.  See 8.302.1 NMAC, General Provider Policies.

                D.            Providers must ensure that prescriptions for eyeglasses or contact lenses are accurate to the extent that the prescription corrects the recipient’s vision to the degree of acuity indicated on the report of vision examination form.

                E.             [Eyeglasses] Eyeglass and contact [lenses] lens suppliers are responsible for verifying that the correct prescription is provided.

                    (1)     If prescriptions are inaccurate and recipients are unable to use their eyeglasses, payment for both the eye examination and the eyeglasses or contact lenses is subject to recoupment.

                    (2)     If the eyeglasses or contact lenses are not ground to the correct prescription, payment for the eyeglasses or contact lenses is subject to recoupment.

[2/1/95; 8.310.6.11 NMAC - Rn, 8 NMAC 4.MAD.715.2 & A, 12/1/03]

 

8.310.6.12             COVERED SERVICES:  Medicaid covers specific vision care services [which] that are medically necessary for the diagnosis and treatment of eye diseases, and for the correction of refractive errors [and visual impairments], as required by the condition of the recipient.  All services must be furnished within the limits of medicaid benefits, within the scope and practice of the medical professional as defined by state law and in accordance with applicable federal, state, and local laws and regulations.

                A.            Exam:  Medicaid covers one routine eye exam for an adult in a twelve month period.

                B.            Eyeglasses:  Medicaid covers [frames and lenses.] one set of corrective lenses for an adult in a twelve-month period, unless an ophthalmologist optometrist recommends a change in prescription due to a medical condition affecting vision.  The vision prescription must be appropriately recorded on the visual examination form.

                    (1)     For the purchase of eyeglasses, the diopter correction must meet or exceed one of the following[, which is called the diopter correction purchase criterion] diopter correction criteria:

                              (a)     -1.00 myopia (nearsightedness);

                              (b)     + 1.00 for hyperopia (farsightedness);

                              (c)     [+ .75] +0.75 astigmatism (distorted vision); [or]

                              (d)     + 1.00 for presbyopia (farsightedness of aging); or

                              (e)     +2.00 for Diplopia (double vision) – prism lenses.

                    (2)     If an existing prescription is updated, there must be a minimum [.75] 0.75 diopter change in the prescription.  Exceptions are considered with prior [approval for recipients with cataracts and recipients under twenty-one (21) years of age who are in school.] authorization for the following:

                              (a)      recipients with cataracts; or

                              (b)     recipients under twenty-one (21) years of age.

                    (3)     Medicaid covers one frame for corrective lenses for an adult in a twenty-four month period.

                    (4)     [If a recipient’s] Eyeglasses or contact lenses that are lost, broken or have deteriorated to the point [where] that, in the examiner’s opinion, they have become unusable to the recipient, [the policy for replacement is as follows] may be replaced for the following:

                              (a)     recipients under twenty-one (21) years of age; or

                              (b)     recipients twenty-one (21) years of age or older who have developmental disabilities.

                    (5)     Documentation for replacement:

                              (a)     the eyeglass or contact lens (or lenses) must meet the diopter correction purchase criterion and must be recorded on the report of visual examination form; and

                              (b)     the loss, deterioration or breakage must be documented in the appropriate section of the visual examination form.

                    (6)     Medicaid covers bifocal lenses with a correction of [.25] 0.25 or more for distance vision and 1 diopter or more for add power (bifocal lens correction).  [Medicaid covers prism lenses with a total correction of 2.00 diopters or more. The diopter correction purchase criterion does not apply.]

                    (7)     Medicaid covers tinted lenses with filtered or photochromic lenses if the examiner documents one or more of the following disease entities, injuries, syndromes or anomalies in the “comments” section of the visual examination form, and the prescription meets the [dioptric] dioptic correction purchase criteria.

                              (a)     aniridia;

                              (b)     albinism, ocular;

                              (c)     traumatic defect in iris;

                              (d)     iris coloboma, congenital;

                              (e)     chronic keratitis;

                              (f)     Sjogren’s syndrome;

                              (g)     aphakia, U.V. filter only if [I.O.L.] intraocular lens is not U.V. filtered; and

                              (h)     rod monochromaly.

                C.            Balance lenses:  Medicaid covers balance lenses without prior [approval] authorization in the following situations:

                    (1)     lenses used to balance an aphakic eyeglass lens; or

                    (2)     recipient is blind in one eye and the visual acuity in the [seeing] eye requiring correction meets the diopter correction purchase criteria.

                D.            Contact lenses:  Medicaid covers contact lenses, either the original prescription or replacement, only with prior authorization.  Requests for prior authorization will be evaluated on dioptric criteria and/or visual acuity, the recipient’s social or occupational need for contact lenses, and special medical need.  The criteria for authorization of contact lenses are as follows:

                    (1)     the recipient must have a diagnosis of keratoconus or diopter correction of +/- -6.00 or higher in any meridian, at least 3.00 diopters of anisometropia.

                    (2)     monocular aphakics may be provided with one contact lens and a pair of bifocal glasses.

                E.             Prisms:  All prisms are covered if medically indicated to prevent diplopia (double vision).  Documentation is required on the visual examination form.

                F.             Lens tempering:  Medicaid covers lens tempering [only when it is billed on the same claim form as a new pair of glasses or lenses] on new glass lenses only.

                G.            Lens edging:  Medicaid covers lens edging and lens insertion.

                H.            Minor repairs:  Medicaid covers minor repairs to eyeglasses.

                I.              Dispensing fee:  Medicaid pays a dispensing fee [which is paid] to ophthalmologists, optometrists, or opticians for dispensing a combination of lenses and new frames. The fee is not paid when contact lenses are dispensed.

                J.             Eye prosthesis:  Medicaid covers eye prostheses (artificial eyes).

[2/1/95; 8.310.6.12 NMAC - Rn, 8 NMAC 4.MAD.715.3 & A, 12/1/03]

 

8.310.6.13             PRIOR [APPROVAL] AUTHORIZATION AND UTILIZATION REVIEW:  All medicaid services are subject to utilization review for medical necessity and program compliance.  Reviews can be performed before services are furnished, after services are furnished and before payment is made, or after payment is made.  See 8.302.5 NMAC, Prior Approval and Utilization Review.  Once enrolled, providers receive instructions and documentation forms necessary for prior approval and claims processing.

                A.            Prior [approval] authorization:  Certain procedures or services can require prior [approval] authorization from MAD or its designee.  Contact lenses, either the original prescription, or replacement, require prior [approval] authorization.  Services for which prior [approval] authorization was obtained remain subject to utilization review at any point in the payment process.

                B.            Eligibility determination:  Prior [approval] authorization of services does not guarantee that individuals are eligible for medicaid.  Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine if medicaid recipients have other health insurance.

                C.            Reconsideration:  Providers who disagree with prior [approval] authorization request denials or other review decisions can request a re-review and a reconsideration.  See 8.350.2 NMAC, Reconsideration of Utilization Review Decisions.

[2/1/95; 8.310.6.13 NMAC - Rn, 8 NMAC 4.MAD.715.4 & A, 12/1/03]

 

8.310.6.14             NONCOVERED SERVICES:  Vision services are subject to the limitations and coverage restrictions [which] that exist for other medicaid services.  See 8.301.3 NMAC, General Noncovered Services.  Medicaid does not cover the following specific vision services:

                A.            orthoptic assessment and treatment;

                B.            photographic procedures, such as fundus or retinal photography and external ocular photography;

                C.            [photochromic lenses or tint] tinted or photochromic lenses, except in cases of documented medical necessity.  See Paragraph (5) of Subsection B of 8.310.6.12 NMAC above.  If a recipient desires tinted or [photogray] photo-gray lenses, the recipient pays the difference between the cost of the tinted or [photogray] photo-gray lenses and the cost of clear lenses;

                D.            additional reimbursement for oversize frames and oversize lenses; the recipient pays the difference between the cost of the oversized frames and/or lenses and the cost of regular sized frames and/or lenses;

                E.             low vision aids;

                F.             eyeglass cases;

                G.            eyeglass or contact lens insurance; and

                H.            [photographic procedures, such as fundus or retinal photography and external ocular photography; and] anti-scratch coating.

[2/1/95; 8.310.6.14 NMAC - Rn, 8 NMAC 4.MAD.715.5 & A, 12/1/03]

 

8.310.6.15             REIMBURSEMENT:

                A.            Vision service providers, except IHS and 638 facilities, must submit claims for reimbursement on the HCFA-1500 claim form or its successor.  See 8.302.2 NMAC, Billing for Medicaid Services.  Once enrolled, providers receive [instructions on documentation, billing, and claims processing] a packet of information, including medicaid program policies, billing instructions, utilization review instructions, and other pertinent material from MAD.

                B.            Reimbursement to vision providers for covered services, procedures and other vision service appliances is made at the lesser of the following:

                    (1)     the provider’s billed charge; or

                    (2)     the MAD fee schedule for the specific service or procedure.

                              (a)     The provider’s billed [charge] charges must be [their] the usual and customary charge for services.

                              (b)     “Usual and customary charge” refers to the amount [which] that the individual provider charges the general public in the majority of cases for a specific procedure or service.

[2/1/95; 8.310.6.15 NMAC - Rn, 8 NMAC 4.MAD.715.6 & A, 12/1/03]