Statutes, codes, and regulations
Colorado Administrative Code
Department 2505 - Department of Health Care Policy and FinancingDivision 2505 - Medical Services Board (Volume 8; Medical Assistance, Children's Health Plan)
Rule 10 CCR 2505-10-8.200 - MEDICAL ASSISTANCE - SECTION 8.200 Physician Services, Dental, Vision Services, Medicaid Managed Care Program, EPSDT
Section 10 CCR 2505-10-8.203 - VISION SERVICES

10 Colo. Code Regs. § 2505-10-8.203

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Current through Register Vol. 47, No. 16, August 25, 2024
Section 10 CCR 2505-10-8.203 - VISION SERVICES
8.203.1Definitions

Adult Client means a Colorado Medicaid client 21 years of age or older.

Comprehensive Eye Exam means the examination, diagnosis, treatment, and management of diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identified related systemic conditions affecting the eye.

Low Vision Aid means one of a range of magnification devices that may be necessary to supplement eyeglasses for people with vision loss or low vision.

Refractive Error means a failure of the eye to focus images sharply on the retina, causing blurred vision.

8.203.2Client Eligibility
8.203.2.A. All Colorado Medicaid clients are eligible for covered vision services, subject to the service-specific criteria and restrictions detailed in this section 8.203.
8.203.3Provider Eligibility
8.203.3.A.Ordering, Prescribing, Referring (OPR) Providers
1. The following providers are eligible to order, prescribe, or refer vision services when enrolled with Colorado Medicaid and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they do business:
a. Optometrists
b. Ophthalmologists
c. Physicians
8.203.3.B.Rendering Providers
1. The following providers are eligible to render vision services when enrolled with Colorado Medicaid and licensed by the Colorado Department of Regulatory Agencies, or the licensing agency of the state in which they do business:
a. Optometrists
b. Ophthalmologists
c. Opticians
8.203.4Covered Services
8.203.4.A.Examinations and Eye Care Services
1. Comprehensive Eye Exam (CEE)
a. Limited to one (1) comprehensive eye exam per client, per calendar year.
2. Post-Comprehensive Eye Exam Follow-Up Visit
a. Covered if medically necessary, as defined in section 8.076.1.8, to address a change in client's condition.
3. Orthoptic and Pleoptic Vision Therapy
a. Covered for a client 20 years of age or younger, when medically necessary, as defined in section 8.076.1.8.
8.203.4.B.Eyeglasses
1. Frames and Lenses- Adult Clients
a. Frames and lenses are covered for an Adult Client if:
i) Client has previously undergone eye surgery; and
ii) Medically necessary, as defined in section 8.076.1.8.
b. Covered frames and lenses for an Adult Client are limited to:
i) One (1) eyeglasses frame; and
ii) Up to two (2) lenses that are:
1) Single or multi-focal;
2) Clear glass or plastic; and
3) Without filters or coatings.
c. Limited to one (1) pair of eyeglasses per Adult Client, per 24-month period.
2. Frames and Lenses- Clients 20 Years of Age or Younger
a. Frames and lenses are covered for a client 20 years of age or younger if:
i) Medically necessary, as defined in section 8.076.1.8;
ii) Prescribed by a provider who meets the criteria at 8.203.3.A.; and
iii) Purchased through a provider who meets the criteria at 8.203.3.B.
b. Per prescription, covered frames and lenses for a client 20 years of age or younger are limited to:
i) One (1) eyeglasses frame; and
ii) Up to two (2) lenses that are:
1) Single or multi-focal; and
2) Clear glass, plastic, or polycarbonate.
8.203.4.C.Contact Lenses
1. Contact lenses are covered for an Adult Client if:
a. Client meets the criteria for eyeglasses frames and lenses in section 8.203.4.B.1.a.; and
b. Eyeglasses are not sufficient to treat the client's refractive error.
2. Contact lenses are covered for a client 20 years of age or younger if:
a. Client meets criteria for eyeglasses frames and lenses in section 8.203.4.B.2.a.; and
b. Eyeglasses are not sufficient to treat the client's refractive error.
8.203.4.D.Ocular Prosthetics

Ocular prosthetics are covered for all clients when medically necessary, as defined in section 8.076.1.8.

8.203.4.E.Low Vision Aids

Low Vision Aids are covered for a client 20 years of age or younger when medically necessary, as defined at section 8.076.1.8.

8.203.4.F.Eyewear Replacement
1. Eyewear replacement is covered for a client 20 years of age or younger in the event of:
a. Loss;
b. A change in prescription; or c. Damage, if the cost to repair exceeds the cost of replacement.
2. Eyewear replacement for a client 20 years of age or younger is limited to the following types of eyewear:
a. Eyeglasses frames and lenses;
b. Contact lenses;
c. Ocular prosthetics; and d. Low vision aids.
3. Eyewear replacement is not covered for Adult Clients.
8.203.5Prior Authorization
8.203.5.A. Prior authorization is not required for vision services described in section 8.203.4.
8.203.6Limitations, Exceptions, Non-Covered Services 8.203.6.A. Non-Covered Services
1. LASIK surgery and other eye surgeries which are not medically necessary.

10 CCR 2505-10-8.203