471 Neb. Admin. Code, ch. 24, § 004

Current through September 17, 2024

Section 471-24-004 - SERVICE REQUIREMENTS

004.01GENERAL REQUIREMENTS

004.01(A) Medical Necessity. Nebraska Medicaid incorporates the definition of medical necessity from 471 NAC 1 as is fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

004.01(B)SERVICES PROVIDED FOR RECIPIENTS ENROLLED IN THE NEBRASKA MEDICAID MANAGED CARE PROGRAM. See 471 NAC 1.

004.01(C)EARLY AND PERIODIC, SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES. See 471 NAC 33.

004.02COVERED SERVICES. Nebraska Medicaid covers medically necessary and appropriate visual care services within program guidelines. Examination, diagnosis and treatment services are also allowable to diagnose or treat a specific eye illness, symptom, complaint, or injury. i

004.02(A)EXAMINATION, DIAGNOSIS, AND TREATMENT SERVICES.

004.02(A)(i)EYE EXAMINATIONS.

004.02(A)(i)(1)RECIPIENTS AGE 21 AND OLDER. Eye examinations are limited to once every 24 months. More frequent eye examinations will be covered when medically necessary and appropriate to diagnose or treat a specific eye illness, symptom, complaint or injury.

004.02(A)(i)(2)RECIPIENTS AGE 20 AND YOUNGER. Eye examinations are limited to once every 12 months. More frequent eve examinations will be covered when medically necessary and appropriate to diagnose or treat a specific eye illness, symptom, complaint, or injury.

004.02(A)(ii)VISION THERAPY. Nebraska Medicaid covers vision therapy, orthopics, and is limited to 22 session.

004.02(B)FRAMES.

004.02(B)(i)COVERAGE CRITERIA. Eyeglass frames are covered once each coverage period when one of the following conditions is met:

(1) A medical reason of:

(a) The individual's first pair of prescription eyeglasses;

(b) Size change needed due to growth; or

(c) A prescribed lens change, only if new lenses cannot be accommodated by the current frame.

(2) The recipient's current frame is no longer useable due to irreparable wear, damage, breakage, or loss.

004.02(B)(ii)COVERAGE PERIOD.

004.02(B)(ii)(1)RECIPIENTS AGE 21 AND OLDER. Eyeglass frames are limited to once every 24 months. Replacement of frames which are irreparable due to breakage or loss, is allowed one additional time per coverage period.

004.02(B)(ii)(2)RECIPIENTS AGE 20 AND YOUNGER. Eyeglass frames are limited to once every 12 months. Eyeglass frames are covered more frequently if medically necessary.

004.02(B)(iii)FRAME SPECIFICATION. The following specifications apply to all eyeglass frames:

(1) Plastic and metal frames are covered: rimless frames are not covered:

(2) Discontinued frames with new prescription lenses are not covered: and

(3) Frame cases are covered with new eyeglasses.

004.02(B)(iv)FRAME REPAIR. Nebraska Medicaid covers frame repair if less costly than providing a new frame and if the repair would provide a serviceable frame for the recipient. Applicable manufacturer warranties are considered to be a third party resource, and must be utilized in accordance with 471 NAC 3.

004.02(C)LENSES.

004.02(C)(i)COVERAGE CRITERIA. Nebraska Medicaid covers one pair of eyeglass lenses each coverage period. If one lens meets the coverage criteria, both lenses may be provided, unless the prescribing practitioner specifies replacement of only one lens. In order to be covered one of the following conditions must be met:

(1) A medical reason including:

(a) The individual's first pair of prescription eyeglasses:

(b) Size change needed due to growth: or

(c) A new prescription with the refraction correction meeting one of the following criteria:

(i) A change of 0.50 diopters in the meridian of greatest change when placed on an optical cross:

(ii) A change in axis in excess of 10 degrees for 0.50 cylinder, 5 degrees for 0.75 cylinder; or

(iii) A change of prism correction of % prism diopter vertically or 2 prism diopters horizontally or more.

(2) The current lenses are no longer useable due to damage, breakage, or loss.

004.02(C)(ii)COVERAGE PERIOD.

004.02(C)(ii)(1)RECIPIENTS AGE 21 AND OLDER, Eyeglass lenses are limited to once every 24 months.

004.02(C)(ii)(2)RECIPIENTS AGE 20 AND YOUNGER. Eyeglass lenses are limited to once every 12 months. Eyeglass lenses are covered more frequently if medically necessary.

004.02(C)(iii)LENS SPECIFICATION. The following specifications apply to all eyeglass lenses:

(1) Lenses are covered only if the refraction correction is at least 0.50 diopters in any meridian:

(2) Plastic or glass lenses are covered:

(3) All plastic lenses must include front surface scratch resistant coating that is factory applied or "in-house" dipped:

(4) Lenses must be of a quality at least equal to Z-80 standards of the American National Standard Institute: and

(5) All lenses dispensed must be prescribed by a licensed practitioner. A copy of the prescribing practitioner's original prescription must be maintained in the provider's records and must be available for review by the Department upon request.

004.02(C)(iv)COVERED SPECIAL LENS FEATURES AND LAB PROCEDURES.

(1) Bifocal and trifocal segments exceeding 28mm if necessary for specific employment or educational purposes, or due to a specific disability which limits head and neck movement

(2) High index lenses if the refraction correction is at least +/- 10.00 diopters in meridian of greatest power when placed on an optical cross.

(3) Myodisc lenses when prescribed.

(4) Nylon cord, metal cord, or rimless mount only when the recipient purchases their own frames or uses previously purchased frames.

(5) Oversize lens charges if medically necessary or if the recipient purchases their own frame or uses previously purchased frame.

(6) Standard polycarbonate lenses for recipients age 20 and younger. For recipients age 21 and older, covered only if prescribed for significantly monocular vision.

(7) Thin polycarbonate lenses for recipients age 20 and younger. For recipients age 21 and older, covered only if the refraction correction is at least +/- 8.00 diopters in the meridian of greatest power when placed on an optical cross.

(8) Scratch resistant coating is required for plastic lenses. Additional scratch resistant coating is not covered.

(9) Slab-off prism if there is at least 3.00 diopters of anisometropia in the vertical meridian.

(10) Special base curve only if prescribed for aniseikonia.

(11) Tint only for chronic disorders which cause significant photophobia under indoor lighting conditions. Simple photophobia is not an accepted diagnosis for coverage.

(12) Ultraviolet lens coating only for chronic disorders that are complicated or accelerated by ultraviolet light.

004.02(C)(v)LENS REPLACEMENT. Replacement of lenses which are irreparable due to wear, damage, breakage, or loss, is limited to once per lens in 12 month period, for recipients age 21 years and older.

004.02(D)EYEGLASS FITTING. Nebraska Medicaid covers fitting of eyeglasses associated with provision Nebraska Medicaid covered lenses, frames, or both. Fitting includes:

(i) Measurement of anatomical facial characteristics:

(ii) Writing of laboratory specifications:

(iii) Ordering eyeglasses:

(iv) Verifying order once received:

(v) Final adjustment of the eyeglasses to the visual axes and anatomical topography:

(vi) Any associated overhead including shipping and postage charges.

(vii) Dispensing: and

004.02(E)CONTACT LENS SERVICES. Contact lens services include prescription, fitting, supervision of adaptation, and supply of contact lenses.

004.02(E)(i)COVERAGE CRITERIA. Nebraska Medicaid covers contact lens services only when prescribed for recipients with:

(1) Keratoconus:

(2) Aphakia excluding pseudophakia:

(3) High plus corrections of - 1-12.00 diopters spherical equivalent or greater due to the visual field defect caused by a high plus correction:

(4) High minus corrections of - 12.00 diopters spherical equivalent or greater, but only with an increase in binocular best visual acuity of at least 2 Snellen lines when comparing the contact lenses to the spectacle lens correction:

(5) Anisometropia, difference in correction of at least 6.00 diopters spherical equivalent in order to avoid double vision; or

(6) Other pathological conditions of the eve when useful vision cannot be obtained with eyeglasses.

004.02(E)(ii)REPLACEMENT CONTACT LENSES. Covered when required due to loss, damage, or for prescription changes when the recipient's condition meets Nebraska Medicaid's criteria for coverage of contact lens services.

004.03NON-COVERED SERVICES. The following services are not covered by Nebraska Medicaid:

004.03(A)EYEGLASSES.

(i) Sunglasses:

(ii) Multiple pairs of eyeglasses for the same individual:

(iii) Non-spectacle mounted aids, hand-held or single lens spectacle mounted low vision aids, and telescopic and other compound lens systems; and

(iv) Replacement insurance.

004.03(B)SPECIAL LENS FEATURES AND LAB PROCEDURES,

(i) Anti-reflective and mirror lens coating;

(ii) Biended and progressive multifocal lenses:

(iii) Drilling, notching, grooving, faceting of lenses;

(iv) Edging or beveling of lenses for cosmetic reasons;

(v) Engraving:

(vi) Roil and polish edges: or

(vii) Photochromatic tints and sunglasses.

004.03(C)CONTACT LENSES.

(i) Prescribed for routine correction of vision: and

(ii) Disposable contact lenses.

471 Neb. Admin. Code, ch. 24, § 004

Repealed effective 12/14/2016.

Amended effective 12/27/2021