D.C. Mun. Regs. tit. 29, r. 29-965

Current through Register 71, No. 45, November 7, 2024

Rule 29-965 - OPTOMETRY SERVICES

965.1

Optometry services related to vision and vision disorders that are obtained for the purpose of diagnosis and treatment, including lenses, frames, other aids to vision, and therapeutic drugs, provided consistent with the requirements set forth in 42 C.F.R. Sections 440.60 (a), 440.120(d), and 441.30, shall be eligible for Medicaid reimbursement.

965.2

Medicaid reimbursement of optometry services shall be limited to specific services set forth in this section and any additional optometry services, identified at www.dc-medicaid.com, which have received prior authorization by the Department of Health Care Finance (DHCF) or its agent.

965.3

Medicaid reimbursement of eye exams for Medicaid beneficiaries over twenty-one (21) years of age shall be limited in the following manner:

(a) The services shall be medically necessary and required to monitor a chronic condition that could harm a beneficiary's vision; or

(b) The beneficiary has an acute condition that, if left untreated, may cause permanent or chronic damage to the eye.

965.4

Medicaid reimbursement of eye exams for Medicaid beneficiaries from birth through twenty-one (21) years of age shall be based on Early Periodic Screening, Diagnosis, and Treatment program requirements, as set forth in 42 C.F.R. Section 440.40 (b).

965.5

Medicaid reimbursement for eyeglasses for Medicaid beneficiaries shall be limited to one (1) complete pair of eyeglasses in a twenty-four (24) month period unless:

(a) The beneficiary is under twenty-one (21) years of age;

(b) The new prescription represents a change of at least +/- 0.50 diopters from the prior prescription;

(c) A prescription represents a change from the prior prescription of at least + 0.75 sphere or - 0.50 sphere, 0.50 cylinder, 1/2 prism diopter vertical, or 3 prism diopter lateral;

(d) There has been a major change in visual acuity documented by an optometrist licensed pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01 et seq.), as amended; and the new lenses cannot be accommodated by a beneficiary's existing eyeglasses; or

(e) The frames or lenses have been lost, broken beyond repair or scratched to the extent that visual acuity is compromised, as determined by the dispensing provider.

965.6

Medicaid reimbursement for Medicaid beneficiaries under twenty-one (21) years of age shall be limited to one (1) complete pair of eyeglasses in a twelve (12) month period.

965.7

The limitations described at Subsections 965.5 through 965.6 shall apply to new, duplications, and changes in a prescription.

965.8

Medicaid reimbursement for repairs or replacements of eyeglasses, contact lenses, glass lenses, ultraviolet lenses, prosthetic eyes, lenses made of polycarbonate or equal material, tinted lenses, and photochromatic lenses shall require prior authorization from DHCF.

965.9

After receiving written documentation that the repair or replacement is medically necessary, DHCF may provide prior authorization for reimbursement.

965.10

Repairs or replacements of eyeglasses, under Subsection 965.8, shall only be reimbursed if ordered in writing by an optometrist licensed pursuant to the District of Columbia Health Occupations Revision Act of 1985, effective March 25, 1986 (D.C. Law 6-99; D.C. Official Code §§ 3-1201.01 et seq.), as amended.

965.11

Reimbursement of optometry services shall be limited to those services provided by optometrists who are screened and enrolled as a District Medicaid program provider pursuant to Chapter 94 of Title 29 of the District of Columbia Municipal Regulations and who adhere to dispensing procedures in the Vision Billing Manual, published on the Department of Health Care Finance's Provider website at www.dc-medicaid.com.

965.99

DEFINITIONS

For the purposes of this section, the following terms shall have the meanings ascribed:

Eyeglasses: 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.

D.C. Mun. Regs. tit. 29, r. 29-965

Final Rulemaking published at 63 DCR 890 (1/22/2016)