C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-75, subsec. 144-101-II-75.03

Current through 2024-51, December 18, 2024

Subsection 144-101-II-75.03 - COVERED SERVICES

MaineCare reimburses for some services differently for members based on age or residence in an ICF-MR. Only an ophthalmologist or optometrist may provide services described in Section 75.03-1.

75.03-1Services That May be Provided Only by an Ophthalmologist or Optometrist

Only an ophthalmologist or optometrist may provide the following services:

A.Eye Exams

For members who are under age twenty-one (21) or who reside in an ICF-MR, MaineCare will pay for one annual routine eye exam. For members ages twenty-one (21) and over, MaineCare will pay for only one routine eye exam every three (3) rolling calendar years, except that routine eye exams indicated as standard of care for specific medical diagnoses (ex. diabetes) or medication use (ex. Plaquenil) will be covered as medically indicated.

1.Eye Examination, Brief - Limited - Minimal

A brief eye examination is a limited or minimal level of service for which evaluation and detection require only a brief history and examination.

Example: A patient visit of 5 to 15 minutes required to evaluate a problem, to re-evaluate a prior problem or abnormality, or for further testing and evaluation of an existing chronic concern.

2.Eye Examination, Intermediate - Extended

An intermediate eye examination is a level of service more extensive than that of a follow-up, substantiated by documentation noting change and/or complication necessitating evaluation and detection of an otherwise stable condition.

3.Eye Examination - Comprehensive

A comprehensive eye examination is a level of service involving an in-depth evaluation of a member with a new or existing problem requiring the development or complete re-evaluation of data.

Example: The examination of the eye and related structures to ascertain defects or abnormalities, to detect the presence of eye diseases, to determine the refractive and accommodative states of the eyes, and to evaluate the visual functions. The eye examination includes a diagnostic history, visual acuity determination, testing for refraction, muscle balance and accommodative function, ophthalmoscopy and biomicroscopy. Tonometry and gross visual field testing should be included when indicated. Other tests may be included as required as long as they fall within the scope of licensure for optometry.

4.Exam Referral Restrictions

An ophthalmologist or optometrist who has provided an eye exam for a member may not refer that member to another vision service provider for the sole purpose of obtaining eyeglasses through the Vision Care Volume Purchase Contractor.

B.Other Studies

Other studies limited to tonography, gonioscopy, fundus photography, anterior segment photography and mydriatic and cycloplegic examinations are covered services

C.Visual Field Testing

The following are covered visual field testing services:

1.Limited Visual Field Testing

Limited visual field testing is screening of the central and/or peripheral visual field, utilizing automatic or semi-automatic methods and devices providing printed record(s) of the visual field. Confrontation or finger fields and Harrington-Flocks type screeners do not by themselves constitute a screening of the visual field.

2.Intermediate and Extended Visual Field Testing

Intermediate and extended visual field testing is testing of the central and/or peripheral visual fields, utilizing automatic or semi-automatic methods and instruments for the detection of diseases of the visual system, such as glaucoma, retinal detachment, and/or neurological disease.

3.Visual Field Testing Requirements

The following requirements apply:

a. There is no minimum age requirement as long as the member is mature enough to respond adequately and correctly, and provide a valid response.

b. Only one baseline screening field may be justified if the member is under the age of twenty-one (21).

c. Repetition of screening field is permitted only when it is medically necessary. In the typical case, this procedure would need to be repeated only every three to five years.

D.Refraction

The refraction test is an eye exam that measures a person's prescription for eyeglasses or contact lenses.

E.Corrective Treatment

Corrective treatment is the use of brief, easily explained and performed home orthoptic therapy or other corrective procedures to preserve, restore, or improve vision or visual functioning. Also, corrective treatments include the correction of improper visual habits and/or ocular hygiene through discussion or demonstration.

F.Orthoptic Therapy/Visual Training

Orthoptic therapy/visual training is the utilization of in-office methods and devices to improve accommodative, heterophoric, or heterotropic conditions.

Providers must request and receive prior authorization from the MaineCare Authorization Unit or its authorized agent for Orthoptic Therapy/Visual Training services.

G.Contact Lenses

1.Members under Age 21

For members under age 21, MaineCare covers contact lenses only for treatment of ocular pathology, or for cases in which visual acuity is not correctable to 20/70 with ophthalmic lenses, but can be improved to 20/70 or better with contact lenses. MaineCare covers initial contact lens(es) and one replacement lens per eye per year.

Providers must request and receive prior authorization from the MaineCare Authorization Unit or its authorized agent for contact lenses.

2.Members Ages 21 and Over

MaineCare does not cover contact lenses for members' ages twenty-one (21) and over.

H. Prosthetics, including artificial eyes and replacing the lens of an eye.

75.03-2Services That May be Provided by An Ophthalmologist, Optometrist or Optician

MaineCare covers the following services when provided by an ophthalmologist, optometrist or optician:

A. Eyeglasses. Eyeglasses are defined as lenses, frames and associated parts and cases. The Contractor will fill prescriptions in minus cylinder form only.

1.Members Ages 21 and Over

For members ages 21 and over, MaineCare will pay for one pair of eyeglasses per lifetime when the power is equal to or greater than 10.00 diopters.

2.Members Under Age 21

For members under age 21, MaineCare will pay for eyeglasses when the refractive error in at least one eye meets at least one of the following definitions:

a. Hyperopia: +1.25 diopter or over

b. Myopia: -0.75 diopter or over

c. Astigmatism: -0.50 diopter or over

Providers must request and receive prior authorization from the MaineCare Authorization Unit or its authorized agent for cases where the refractive error is below the criteria set forth above. The Prior Authorization Unit or its authorized agent will require written justification of the medical necessity in such cases.

3.Dispensing

The dispensing process, once initiated, must include: initial fitting, selection, adjustment, and processing of the prescription order prior to manufacture; inspection and verification of the completed order; bending and adjusting of eyeglasses and lenses at the time of dispensing; and additional adjusting as required for best visual use and continued comfort.

MaineCare providers may not impose an extra charge for adjusting and fitting of eyeglasses made after the initial dispensing process regardless of who has dispensed the eyeglasses.

MaineCare providers may not refuse to fill a prescription for eyeglasses if the member presents the provider with a valid, current prescription for eyeglasses from an ophthalmologist or optometrist, unless it is standard practice for the provider to refuse to do so for non-MaineCare members as well. Additionally, MaineCare providers may not require that the member submit to another eye exam in order to fill a prescription if the member presents the provider with a valid, current prescription for eyeglasses from an ophthalmologist or optometrist.

4.Lenses and Frames

a. Providers must order lenses, frames, and frame parts through the Department's designated Vision Care Volume Purchase Contractor (the Contractor).

b. If the frame has been damaged, MaineCare will pay for a frame of identical style if the lenses are still serviceable. If an identical frame is not available or a change in size is required, MaineCare will cover the cost of a new frame and lenses.

Members have the option to have replacement lenses fitted into their existing MaineCare contract-frame, with the exception of oversize lenses as noted in Section 75.05.

c. Providers must request and receive prior authorization from the MaineCare Authorization Unit or its authorized agent for frames and/or lenses that cost more than the MaineCare maximum allowance and/or for medically necessary frames and or lenses that cannot be provided by the Contractor. Providers must supply clinical documentation indicating medical necessity, e.g., allergy to materials used by Contractor. MaineCare will reimburse providers at the wholesale cost, not to exceed $70.00 per frame. MaineCare will pay no part of the cost of eyeglasses unless prior authorization is obtained from the MaineCare Authorization Unit or authorized agent.

d. Tint, photochromatic, or ultraviolet lenses are covered by MaineCare when medical documentation, including appropriate diagnosis and confirming tests and lab results, is maintained in the member's medical record and made available to the Department upon request. Ultraviolet (UVA and UVB) must not be ordered by the provider and will not be additionally reimbursed by the Department when it is an indigenous feature of the lens, such as with a polycarbonate lens. The diagnosis code indicating the medical necessity of the service must be submitted on the order form to the Contractor when ordering tint, photochromatic or ultraviolet lenses. For members age twenty-one (21) and older, the following additional requirements must be met:

a. For ultraviolet lenses, the member must have had cataract extraction.

b. For tint and photochromatic lenses, the member must have a medical condition that induces photophobia, which must be confirmed by one of the following tests: ophthalmoscopy and slit lamp examination, corneal scraping or lumbar puncture.

5.Repair Options

Members may choose from three options for the repair of covered eyeglasses:

a. The provider sends the eyeglasses to the Contractor for repair. The Contractor bills the Department for any parts and repair. The Contractor is responsible for furnishing postage-paid mailers to MaineCare providers for use in returning materials to the Contractor; or

b. The provider orders any necessary parts from the Contractor. The Contractor bills the Department for any parts. The provider bills the Department for the repair only; or

c. The provider orders any necessary part(s) for covered eyeglasses from its usual and customary supplier and pays that supplier. The provider bills the member for any parts and bills MaineCare for the repair.

B.Low-Vision Aids

MaineCare pays for low-vision aids only when best correctable vision of 20/70 or poorer can be improved to a more useful level for specific visual tasks. Examples include, but are not limited to: telescopic compound lens system, hand-held magnifiers.

Providers must request and receive prior authorization from the MaineCare Authorization Unit or its authorized agent for low-vision aids.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-75, subsec. 144-101-II-75.03