Okla. Admin. Code § 317:30-5-432.1

Current through Vol. 42, No. 4, November 1, 2024

Section 317:30-5-432.1 - Corrective lenses and optical supplies

(a) When medically necessary, payment will be made for lenses, frames, low vision aids and certain tints for children. Coverage includes lenses and frames to protect children with monocular vision. Coverage includes two sets of non-high-index polycarbonate lenses and frames per year. Any lenses and frames beyond this limit must be prior authorized and determined to be medically necessary. All non-high-index lenses must be polycarbonate.

(b) Corrective lenses must be based on medical need. Medical need includes a significant change in prescription or replacement due to normal lens wear.

(c) SoonerCare provides frames when medically necessary. Frames are expected to last at least one year and must be reusable. If a lens prescription changes, the same frame must be used if possible.

(d) Providers must accept SoonerCare reimbursement as payment in full for services rendered, except when authorized by SoonerCare (e.g., copayments, other cost sharing arrangements authorized by the State).

(1) Providers must be able to dispense standard lenses and frames which SoonerCare would fully reimburse with no cost to the eligible member.

(2) If the member wishes to select lenses and frames with special features which exceed the SoonerCare allowable fee, and are not medically necessary, the member may be billed the excess cost. The provider must obtain signed consent from the member acknowledging that they are selecting lenses and/or frames that will not be covered in full by SoonerCare and that they will be responsible to pay the excess cost. The signed consent must be included in the member's medical record.

(e) Replacement of or additional lenses and frames are allowed when medically necessary. The OHCA does not cover lenses or frames meant as a backup for the initial lenses/frames. Prior authorization is not required unless the number of glasses exceeds two per year. The provider must always document in the member record the reason for the replacement or additional lenses and frames . The OHCA or its designated agent will conduct ongoing monitoring of replacement frequencies to ensure OHCA policy is followed. Payment adjustments will be made on claims not meeting these requirements.

(f) A fitting fee will be paid if there is documentation in the record that the provider or technician took measurements of the member's anatomical facial characteristics, recorded lab specifications and made final adjustment of the spectacles to the visual axes and anatomical topography. A fitting fee can only be paid in conjunction with a pair of covered lenses and frames.

(g) Bifocal lenses for the treatment of accommodative esotropia are a covered benefit. Progressive lenses, trifocals, photochromic lenses and tints for children require prior authorization and must satisfy the medical necessity standard. Payment is limited to two glasses per year. Any glasses beyond this limit must be prior authorized and determined to be medically necessary.

(h) Progressive lenses, aspheric lenses, tints, coatings and photochromic lenses for adults are not compensable and may be billed to the patient.

(i) Replacement of lenses and frames due to abuse and neglect by the member is not covered.

(j) Bandage contact lenses are a covered benefit for adults and children. Contact lenses for medically necessary treatment of conditions such as aphakia, keratoconus, following keratoplasty, aniseikonia/anisometropia or albinism are a covered benefit for adults and children. Other contact lenses for children require prior authorization and must satisfy the medical necessity standard.

Okla. Admin. Code § 317:30-5-432.1

Added at 25 Ok Reg 653, eff 2-1-08 through 7-14-08 (emergency)¹; Added at 25 Ok Reg 2634, eff 7-25-08

Amended by Oklahoma Register, Volume 32, Issue 23, August 17, 2015, eff. 8/27/2015

Amended by Oklahome Register, Volume 33, Issue 23, August 15, 2016, eff. 9/1/2016

Amended by Oklahoma Register, Volume 34, Issue 23, August 15, 2017, eff. 9/1/2017

¹This emergency action expired before being superseded by a permanent action. Upon expiration of an emergency action enacting a new Section, the Section is no longer effective. Therefore, on 7-15-08 (after the 7-14-08 expiration of this emergency action), Section 317:30-5-432.1 was no longer effective, and remained as such until added again by permanent action on 7-25-08.