Ala. Admin. Code r. 560-X-17-.04

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-17-.04 - Eyeglasses

(1) Authorization

(a) Recipients under 21 years of age are authorized two pair of glasses each year if indicated by an examination; a prior authorization will be required for subsequent pairs requested in a calendar year. Recipients 21 years of age and older are authorized one pair of eyeglasses every two calendar years if indicated by an examination; a prior authorization will be required for subsequent pairs requested within two calendar years. These limitations also apply to fittings and adjustments.

(b) Additional eyeglasses which are medically necessary may be prior authorized by Medicaid for treatment of eye injury, disease or significant prescription change.

(c) The provider should forward a letter to Medicaid justifying medical necessity prior to ordering the eyeglasses (reference Rule No. 560-X-17-.01(3).

(d) A response of either approval or denial will be returned to the provider. If approved, a prior authorization number will be assigned (reference Rule No. 560-X-17-.01(3)

(e) If a patient desires frames or lenses other than those covered by Medicaid he/she must pay the complete cost of the eyeglasses, including fitting and adjusting; Medicaid will not pay any part of the charge. To prevent possible later misunderstanding, the provider should have the patient sign the following statement for retention with the patient's records: "I hereby certify that I have been offered Medicaid eyeglasses but prefer to purchase the eyeglasses myself."

(2) Procurement. At the option of the provider making the frame measurements, eyeglasses in conformance with Medicaid standards, may be procured from either the central Medicaid source or from any other source. Medicaid will pay no more than the contract price charged by the central source.

(3) Standards and Price of Frames.

(a) A list of authorized frames and contract prices is available in the Alabama Medicaid Provider Manual.

(b) The authorized frames, or frames of equal quality, will be provided for Medicaid recipients at the contract prices shown on the list. (Under normal circumstances the date of service for eyeglasses will be the same as the date of examination.)

(c) Patients having old frames, which meet Food and Drug Administration (FDA) impact-resistant regulations and conform to ANSI requirements may have new lenses installed in lieu of being issued new eyeglasses. Medicaid will pay for the lenses only. The following statement should be documented in the recipient's record: "I hereby certify that I used this patient's old frames and that I did not accept any remuneration therefore."

(d) Services provided under this sub-paragraph are subject to the program benefit limitations.

(4) Lenses.

(a) Lens specifications are authorized at the specified contract price.

(b) Lenses will be of clear glass, plastic, or polycarbonate unless prior authorized by Medicaid because of unusual conditions, as indicated in Rule 560-X-17-.01(3). All lenses will meet FDS impact-resistant regulations.

(c) Spherical lenses must be at least a plus or minus .50 diopters; the minimum initial correction for astigmatism only (no other error) is .50 diopters.

(5) Services.

Services reimbursed for eyeglass procurement are: eye examination, including refraction; filling the lens prescription; supplying the frame; and frame fitting, including frame service, verification, and subsequent service.

Ala. Admin. Code r. 560-X-17-.04

Rule effective October 1, 1982. Amended: effective June 8, 1985. Emergency rule effective December 1, 1986. Amended: effective March 12, 1987; January 13, 1988; March 13, 1993. Amended: Filed January 17, 2012; Refiled February 17, 2012; effective February 21, 2012. Amended: Filed July 12, 2012; effective August 16, 2012. Amended: Filed May 9, 2013; effective June 13, 2013.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 09, June 30, 2021, eff. 8/14/2021.

Author: Elizabeth Huckabee, Program Manager; Physician and EPSDT Unit

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. § 435.520(3), 441.30(a)(b); State Plan, Attachment 3.1-A, pages 2.2, 5.1.