Minn. R. agency 196, ch. 9505, MEDICAL ASSISTANCE PAYMENTS, pt. 9505.0277

Current through Register Vol. 49, No. 19, November 4, 2024

Part 9505.0277 - EYEGLASS SERVICES

Subpart 1.Definitions.

The following terms used in this part have the meanings given them.

A. "Comprehensive vision examination" means a complete evaluation of the visual system.

B. "Dispensing services" means the technical services necessary for the design, fitting, and maintenance of eyeglasses as prescribed by an optometrist or ophthalmologist.

C. "Eyeglass services" means comprehensive and intermediate vision examinations provided by and within the scope of practice of a provider who is an optometrist or ophthalmologist and the eyeglasses provided by an optician, optometrist, or ophthalmologist.

D. "Eyeglasses" means a pair of lenses mounted in a frame and other aids to vision prescribed by an optometrist or ophthalmologist.

E. "Intermediate vision examination" means an evaluation of a specific visual problem.

F. "Medically necessary eyeglasses" means that:

(1) for initial eyeglasses, there is a correction of .50 diopters or greater in either sphere or cylinder power in either eye; or

(2) for a change in eyeglasses, there is a change in correction of .50 diopters or greater in either sphere or cylinder power in either eye, or a shift in axis of greater than ten degrees in either eye. For purposes of this item, "diopter" means the unit of refracting power of the lens.

G. "Ophthalmologist" means a physician who has academic training in ophthalmology beyond the requirements for licensure under Minnesota Statutes, chapter 147, and experience in the treatment and diagnosis of diseases of the eye.

H. "Optician" means a supplier of eyeglasses to a recipient as prescribed by the recipient's optometrist or ophthalmologist.

I. "Optometrist" means a person licensed under Minnesota Statutes, sections 148.52 to 148.62.

Subp. 2.Covered eyeglass services.

The eyeglass services in items A to E are eligible for medical assistance payment.

A. Comprehensive vision examinations.

B. Intermediate vision examinations.

C. An initial pair of medically necessary eyeglasses.

D. A pair of eyeglasses that are an identical replacement of a pair of eyeglasses that was misplaced, stolen, or irreparably damaged.

E. A new pair of eyeglasses due to a change in the recipient's head size, a change in vision after a comprehensive or intermediate vision examination shows that a change in eyeglasses is medically necessary, or an allergic reaction to the eyeglass frame material. For purposes of this part, "change in eyeglasses" means a change in prescription.

Subp. 3.Excluded services.

The following eyeglass services are not eligible for payment under the medical assistance program.

A. Services provided for cosmetic reasons. Examples are:

(1) contact lenses prescribed for reasons other than aphakia, keratoconus, aniseikonia, marked acuity improvement over correction with eyeglasses, or therapeutic application; and

(2) replacement of lenses or frames due to the recipient's personal preference for a change of style or color.

B. Dispensing services related to noncovered services.

C. Fashion tints and polarized lenses, unless medically necessary.

D. Protective coating for plastic lenses.

E. Edge and antireflective coating of lenses.

F. Industrial or sport eyeglasses unless they are the recipient's only pair and are necessary for vision correction.

G. Eyeglasses, lenses, or frames that are not medically necessary.

H. Invisible bifocals or progressive bifocals.

I. An eyeglass service for which a required prior authorization was not obtained.

J. Replacement of lenses or frames due to the provider's error in prescribing, frame selection, or measurement. The provider making the error is responsible for bearing the cost of correcting the error.

K. Services or materials that are determined to be experimental or nonclinically proven by prevailing community standards or customary practice.

L. Repair of eyeglasses during the warranty period if the repair is covered by warranty.

M. Purchase of eyeglasses or lenses not covered by a contract obtained through the competitive bidding process under part 9505.0200.

N. Backup eyeglasses.

O. Photochromatic lenses except for a person who has a diagnosis of albinism, achromatopsia, aniridia, blue cone monochromatism, cystinosis, or retinitis pigmentosa, or any other condition for which such lenses are medically necessary.

P. Transition lenses.

Minn. R. agency 196, ch. 9505, MEDICAL ASSISTANCE PAYMENTS, pt. 9505.0277

19 SR 2004

Statutory Authority: MS s 256B.04; 256B.0625