Ala. Admin. Code r. 480-5-5-.17
Current through Register Vol. 43, No. 1, October 31, 2024
Section 480-5-5-.17 - Optometric Services(1) Covered Expenses (a) Only services and products necessitated by an on-the-job injury or illness shall be covered. Such services and, or products shall be provided as a result of damage to the eye(s) due to a work injury or exposure. In addition, lenses and contact lenses not originally purchased by the employer shall be repaired or replaced if damaged or broken in a work-related accident.(b) There are three distinct types of covered services: (c) The reimbursement allowed for contact lenses shall include the normal follow-up to check for proper fit, vision correction and comfort. Any other follow-up services routinely provided free of charge by the provider to other patient or customers shall be provided free of charge to workers' compensation claimants.(2) Benefit Detail and Limitations (a) Upgrades shall not be payable by the employer/agent unless specifically justified on medical grounds or as a replacement for eyewear of like-quality damaged in an on-the-job injury.(b) Covered vision care services shall include examinations, lenses, frames, and contact lenses prescribed by at licensed physician (M.D. or D.O.), or by an optometrist (O.D).(c) Lenses shall be like kind and quality and shall meet American National Standard Institute's standard Z80.1 or Z80.2.(d) Standard eyeglass frames adequate to hold lenses which qualify for payment shall be covered. Any additional charges for "oversize" or designer frames shall be the claimant's liability.(e) Therapeutic contact lenses shall be covered if the patient's visual acuity cannot otherwise be corrected to 20/70 in the better eye or if they are the only effective treatment and shall be inclusive of the fee for the initial clearing and storage kits.(f) The contact lens suitability examination shall be included in the dispensing fee if the claimant is able to wear contact lenses or payable as a separate expense if the claimant is unable to wear contact lenses.(g) Prism, slab-off prism, and special base curve lenses shall be covered when prescribed due to their therapeutic necessity.(h) Payment for covered frames and lenses shall be based on the provider's net acquisition cost. 1. Net acquisition cost shall include the frame, the lens ground on both sides with the edges ground for placement in the frame, plus laboratory cost associated with mounting in the frame, and applicable sales tax. The component of net acquisition cost shall consist of: (i) Material costs: (I) Cost (including shipping and handling) of lens blank purchased directly from the manufacturer or wholesaler; and(II) Rose tints or their equivalent, when prescribed for therapeutic reasons;(ii) Laboratory Costs: (I) Grinding to prescription;(V) Application of tints when prescribed, if not provided by manufacturer;(VII) Laboratory overhead. iii. Applicable Sales Tax(3) The dispensing fee shall compensate a provider for dispensing lenses and frames pursuant to this Rule. It shall include measuring and verifying the lenses as well as selecting, fitting, and adjusting the frames. There shall be a unique reimbursement for single vision, bifocal, or trifocal lenses. Contact lenses and special lenses shall be given individual consideration based on reported details and circumstances.(4) Reimbursement shall be based upon the Maximum Fee Schedule for Optometrists or a mutual agreement pursuant to Code of Ala. 1975, § 25-5-314. Author: Workers' Compensation Division
Ala. Admin. Code r. 480-5-5-.17
New Rule: Filed August 9, 1996; effective September 13, 1996.Statutory Authority:Code of Ala. 1975, § 25-5-293.