Haw. Code R. § 17-1737-76

Current through November, 2024

Section 17-1737-76 - Visual services

(a) Visual or optometric services means services provided by an ophthalmologist or optometrist licensed to practice under state law to correct visual problems within the limits of their professional fields and includes the dispensing of prescription eyeglasses on the written prescription of a licensed practitioner.

(b) Visual services shall include:

(1) Professional services limited to:

(A) Eye examinations;

(B) Refraction, with coverage of a second refraction for persons under the age of eighteen years within twelve months, or eighteen years or older within twenty-four months only when indicated by symptoms. The provider shall make a reasonable effort to determine the date of any previous refraction; and

(C) Vision analysis;

(2) Prescription eyeglasses:

(A) When, for single vision lenses, the refractive correction is at least:

(i) For an original prescription, (+) or (-) 0.50 diopter, sphere or cylinder, or 1 vertical or 5 horizontal prism diopters; or

(ii) For a change in prescription of (+) or (-) 0.50 diopter, or sphere or cylinder, or 6 degrees in cylinder axis;

(B) Which may have single vision, bifocal, or prism lenses made of glass or plastic. Glass lenses shall conform to standard Z-80 (National Bureau of Standards) as it existed on September 15, 1983;

(C) But, exclusions shall be that:

(i) Trifocal lenses shall be covered only for those persons who are currently wearing these lenses satisfactorily and for specific job requirements;

(ii) Tinted or coated corrective lenses shall be included only for persons with aphakia, albinism, glaucoma, or other medical conditions of the eyes exclusive of photophobia not associated with such conditions. Lights transmission shall be adequate to permit use of the lenses indoors and at night;

(iii) Oversize lenses shall not be covered; and

(iv) Bilateral piano glasses shall be covered as safety glasses for persons with one remaining functioning eye;

(D) Along with the case and frame, and repair or replacement of any part;

(E) Individuals with presbyopia who require no or minimal distance correction shall be fitted with ready-made half glasses instead of bifocals; and

(F) Where applicable following cataract extraction with or without insertion of an intraocular prosthetic lens, ready-made temporary glasses shall be rented or purchased until healing has occurred and change in refractive error has stabilized;

(3) Related services which include:

(A) Verification of prescription and dispensing of eyeglasses;

(B) Fitting to include facial measurements; and

(C) Adjustment of glasses;

(4) Contact lenses of all types covered in accordance with the following limitations:

(A) Keratoconus in one or both eyes where corrected vision by glasses is less than 20/40 and the vision is further improved by contact lenses;

(B) Corneal astigmatism in one or both eyes greater than 4.00 diopter and the astigmatism correctable by contact lenses;

(C) Irregular astigmatism due to corneal imperfection where corrected vision by glasses is less than 20/40 and vision is further improved by contact lenses;

(D) Anisometropia due to aphakia or other causes where the vision corrected by glasses in the non-affected eye is less than 20/50, the problem either will last for at least six months or is permanent, and the person requires binocular vision for educational or job purposes;

(E) Bilateral aphakia when a person becomes ill using spectacle glasses or when the person's occupation makes the wearing of glasses hazardous;

(F) Certain inflammatory conditions of the cornea for which therapeutic contact lenses are indicated with the recommendation of an ophthalmologist; and

(G) Not where there are:

(i) Elderly persons beyond the working age with aphakia where the corrected vision in the non-aphakia eye with glasses is 20/50 or better, and the addition of a contact lens will not make the person economically productive; and

(ii) Solely cosmetic purposes such as obscuring an opaque pupil;

(5) Subnormal visual aids; and

(6) Replacement of glasses or contact lenses limited to one pair or unit in a twenty-four month period.

(c) Approval shall be required to obtain contact lenses, subnormal visual aids costing more than $50, and to replace glasses or contact lenses within two years, and shall include one or more of the following

(1) The date and circumstances of loss;

(2) The date the previous glasses were made;

(3) The visual acuity without and with correction; or

(4) The refractive prescription and the previous prescription, if a change is being requested.

(d) Bifocal lenses do not require authorization but claims for these lenses for persons under forty years of age shall include adequate medical justification.

(e) Excluded services and materials shall be:

(1) Visual training and exercise lessons;

(2) Tinted or absorptive lenses except as stated in subsection (b)(2)(C)(ii);

(3) Oversize lenses except for replacement of lenses only;

(4) Contact lenses for cosmetic purposes;

(5) Bifocal contact lenses;

(6) Blended bifocals; and

(7) All services or materials not in compliance with the preceding restrictions.

Haw. Code R. § 17-1737-76

[Eff 08/01/94] (Auth: HRS § 346-14) (Imp: 42 C.F.R. §§440.120, 440.230, 441.30 )