N.Y. Comp. Codes R. & Regs. tit. 18 § 505.6

Current through Register Vol. 46, No. 45, November 2, 2024

Section 505.6 - Ophthalmic services

(a)Definitions.

(1)Qualified optometrist shall mean an optometrist who is licensed and currently registered by the New York State Education Department or, if in practice in another state, by the appropriate agency of that state.

(2)A qualified dispenser shall mean an ophthalmic dispenser who is licensed and currently registered by the New York State Department of Education or, if in practice in another state by the appropriate agency of that state.

(3)Low vision shall mean 20/70 or less in the best eye with best correction.

(b)General policy.

(1) Examinations for visual defects and/or eye disease shall be provided to medical assistance recipients only as necessary and as required by the individual's particular condition. For each medical assistance patient reimbursement for examinations shall be limited to once every two years unless otherwise justified as clinically necessary.

(2) Except in unusual circumstances, eyeglasses shall not be prescribed or provided for a person unless the initial correction or change in correction is at least 1/2 diopter. Any exception to this standard shall be clearly documented by the examining practitioner and shall require prior approval of the local professional director.

(3) Eyeglasses shall be provided only on the basis of proper examination by and with a written prescription of a licensed opthalmologist or optometrist. Eyeglasses shall not normally require changing more frequently than every two years. Any exception to this standard shall be justified as being clinically necessary.

(4) When dispensing eyeglasses, the optometrist or opthalmic dispenser shall complete the following tasks:

(i) measure the interpupillary distances;

(ii) determine the proper bridge, eye and temple size;

(iii) determine the multi-focal position;

(iv) assist the recipient in frame selection; and

(v) supply the recipient with a pair of eyeglasses which are fully assembled and completed.

(5) Fabrication of eyeglasses shall conform to the current American National Standards Institute (ANSI) prescription requirements.

(6) The following standards shall be observed in providing lenses and frames:

(i) All lenses, frames and frame parts shall be guaranteed by the provider against defects in manufacture or assembly.

(ii) Only first quality frames shall be supplied. The dispenser shall be responsible for any needed replacement or repairs that are due to defects in quality of material or workmanship.

(iii) Cost of frames provided shall not exceed the maximum amount approved by the NYS Director of the Budget, except, that for clinical reasons documented by the prescribing ophthalmologist or optometrist, more expensive frames may be approved for an individual. However, where such an exception is made, prior approval by the local professional director shall be required.

(iv) No extra charge shall be made by a dispenser of eyeglasses for future fittings and adjustments if he/she has dispensed the eyeglasses.

(7) Provision of two pairs of eyeglasses, one pair for distance and one for near vision shall not be made unless the need for such pairs shall be substantiated by the patient's particular needs, such as proven inability to tolerate bifocals, the unusual nature of the patient's correction, physical ailments, and other conditions which make provision of bifocals inadvisable. Two pairs of eyeglasses shall not be provided merely as an alternative to satisfy an unjustifiable preference on the part of the patient, for personal convenience or for cosmetic purposes.

(8) For each medical assistance patient examined, a proper record must be maintained by the service provider(s) and, if applicable to the service provided, must include the following information:

(i) examination findings;

(ii) visual field charts;

(iii) orthoptic evaluation records;

(iv) tonometric pressure;

(v) contact lens records;

(vi) fitting measurements; and

(vii) identifying lens and frame specifications.

A record of the prescription must be maintained by the prescriber in the patient's file.

(9) An eye examination provided by a qualified optometrist to be accepted as the basis for prescription for eyeglasses to be reimbursable under medical assistance program shall include, as a minimum, the following components:

(i) case history;

(ii) internal and external eye examination;

(iii) vision correction;

(a) objective;

(b) subjective (distance and near);

(iv) binocular coordination testing (distance and near);

(v) gross visual fields by confrontation;

(vi) tonometry for patients age 35 and over and for others where indicated.

(10) A complete examination by an ophthalmologist shall include the minimal components listed in paragraph (9) of this subdivision and any additional study and medical evaluation including the use of drugs, necessary to arrive at a medical diagnosis.

(11) Optometrists may perform low vision examinations only after passing a qualifying examination in low vision given by the New York State Optometric Association. Prior approval shall not be required for a low vision examination when performed by a licensed ophthalmologist or qualified optometrist.

(12) State reimbursement or payment shall not be available for a low vision examination when such examination is included in and part of any other eye examination and/or eye refraction provided by a practitioner to an individual patient.

(13)

(i) Provision of orthoptic training requires prior approval of the local professional director. No such approval shall exceed six months. If the need for orthoptic training exceeds this six-month period, it is necessary to reapply for prior approval and supply information which details the progress made, the anticipated treatment plan and the prognosis.

(ii) Orthoptic training shall be provided only by a licensed ophthalmologist, a qualified orthoptic technician under the direct supervision of a licensed ophthalmologist or by a qualified optometrist.

(14) Artificial eyes require the recommendation of a licensed opthalmologist and shall require approval by the local professional director.

(15) Contact lenses shall be supplied only for the treatment of ocular pathology and shall require the written recommendation or prescription of a licensed opthalmologist. Prior approval by the local professional director shall be required for all contact lens services.

(c)Authorization for supplies.

(1) The identification card issued to persons eligible for medical assistance shall constitute full authorization for providing the following services and supplies and no special or prior approval shall be required:

(i) single vision or multi-focal lenses as required by the patient's need and conditions;

(ii) case hardened lenses, except as provided in subparagraph (2)(ii) of this subdivision;

(iii) frames with a wholesale cost of not more than the maximum amount approved by the New York State Director of the Budget.

(2) Prior approval of the local professional director shall be required for the following supplies:

(i) tinted lenses;

(ii) case hardened lenses for purposes of industrial safety;

(iii) contact lenses. These lenses are to be provided for ocular pathology only and must be recommended by a licensed ophthalmologist;

(iv) frames with a wholesale cost in excess of the maximum amount approved by the New York State Director of the Budget;

(v) low vision aids costing in excess of $100;

(vi) visual rehabilitation;

(vii) eyeglasses when the initial correction or change correction is less than 1/2 diopter;

(viii) single vision; over standard chart thickness lenses; standard chart thickness shall be that as defined by the American National Standards Institute;

(ix) artificial eye services; and

(x) orthoptic training for which prior approval will be granted for periods of up to six months in duration.

(d)Basis of payment.

Reimbursement and payment for ophthalmic supplies and services shall not exceed the fees contained in the current New York State Fee Schedule for ophthalmic supplies and services approved by the New York State Budget Director as set forth in section 537.3 of this Subchapter.

(e)Acquisition of supplies.

(1) The department will purchase from the Department of Correctional Services all eyeglass lenses and frames to be furnished under the medical assistance (MA) program to recipients of MA and the Department of Correctional Services will assume full responsibility for the provision of such eyeglass lenses and frames to optometrists, qualified dispensers, and retail optical establishments for dispensing to recipients of MA in accordance with the provisions of this subdivision.

(2) Prior to the Department of Correctional Services' assumption of responsibility for providing such eyeglass lenses and frames, the Department of Correctional Services will enter into an agreement with the department for the acquisition of eyeglass lenses and frames by the department and for distribution of such eyeglass lenses and frames by the Department of Correctional Services to enrolled optometrists, qualified dispensers, and retail optical establishments. Such agreement will provide for the prompt provision of ordered supplies, assure that the supplies provided meet appropriate fabrication requirements and standards, and contain such other provisions as the department and the Department of Correctional Services deem appropriate for the efficient and effective distribution of such materials. For purposes of this subdivision, the Department of Correctional Services will guarantee lenses, frames, and frame parts against defects in manufacture or assembly and will be responsible for any needed replacements or repairs that are due to defects in quality of material or workmanship.

(3) On and after the dates specified below, optometrists, qualified dispensers, and retail optical establishments must obtain from the Department of Correctional Services all eyeglass lenses and frames to be dispensed under the MA program to recipients of MA, who have received their authorizations for MA from the following specified social services districts:

(i) Albany County:	July 1, 1994;
(ii) Allegany County:	October 31, 1994;
(iii) Broome County:	April 1, 1993;
(iv) Cattaraugus County:	October 31, 1994:
(v) Cayuga County:	July 1, 1994;
(vi) Chautauqua:	October 31, 1994;
(vii) Chemung County:	October 31, 1994;
(viii) Chenango County:	July 1, 1994;
(ix) Clinton County:	July 1, 1994;
(x) Columbia County:	July 1, 1994;
(xi) Cortland County:	July 1, 1994;
(xii) Delaware County:	April 1, 1993;
(xiii) Dutchess County:	January 15, 1994;
(xiv) Erie County:	October 31, 1994;
(xv) Essex County:	July 1, 1994;
(xvi) Franklin County:	July 1, 1994;
(xvii) Fulton County:	July 1, 1994;
(xviii) Genesee County:	January 15, 1994;
(xix) Greene County:	July 1, 1994;
(xx) Hamilton County:	July 1, 1994;
(xxi) Herkimer County:	July 1, 1994;
(xxii) Jefferson County:	July 1, 1994;
(xxiii) Lewis County:	July 1, 1994;
(xxiv) Livingston County:	January 15, 1994;
(xxv) Madison County:	July 1, 1994;
(xxvi) Monroe County:	January 15, 1994;
(xxvii) Montgomery County:	July 1, 1994;
(xxviii)Nassau County:	October 31, 1994;
(xxix) Niagara County:	October 31, 1994;
(xxx) Oneida County:	July 1, 1994;
(xxxi) Onondaga County:	July 1, 1994;
(xxxii) Ontario County:	January 15, 1994;
(xxxiii) Orange County:	April 1, 1993;
(xxxiv) Orleans County:	January 15, 1994;
(xxxv) Oswego County:	July 1, 1994;
(xxxvi) Otsego County:	July 1, 1994;
(xxxvii) Putnam County:	January 15, 1994;
(xxxviii) Rensselaer County:	July 1, 1994;
(xxxix) Rockland County:	January 15, 1994;
(xl) St. Lawrence County:	July 1, 1994;
(xli) Saratoga County:	July 1, 1994;
(xlii) Schenectady County:	July 1, 1994;
(xliii) Schoharie County:	July 1, 1994;
(xliv) Schuyler County:	October 31, 1994;
(xlv) Seneca County:	October 31, 1994;
(xlvi) Steuban County:	October 31, 1994;
(xlvii) Suffolk County:	October 31, 1994;
(xlviii) Sullivan County:	April 1, 1993;
(xlix) Tioga County:	April 1, 1993;
(l) Tompkins County:	July 1, 1994;
(li) Ulster County;	April 1, 1993;
(lii) Warren County:	July 1, 1994;
(liii) Washington County:	July 1, 1994;
(liv) Wayne County:	January 15, 1995;
(lv) Westchester County:	July 1, 1994; and
(lvi) Wyoming County:	October 31, 1994; and
(lvii) Yates County:	October 31, 1994; and

(4)

(i) Optometrists, qualified dispensers and retail optical establishments rendering supplies to recipients of MA, who have received their authorizations from the above- specified social services districts, must not submit claims for any eyeglass lenses or frames provided on or after the date specified for such district. However, such providers will continue to submit claims to the department for other optical care and services rendered on and after the date specified for each such district.

(ii) The Department of Correctional Services will submit claims to the department for the eyeglass lenses and frames furnished to such providers for dispensing to recipients of MA, who have received their authorizations from the above-specified social services districts, on and after the date specified for each such district.

(5) This subdivision will be effective only if Federal financial participation is available for services provided hereunder to recipients of MA in federally participating categories of assistance.

(6) Optometrists, qualified dispensers and retail optical establishments rendering supplies to recipients of MA, who have received their authorizations from the above-specified social services districts, may obtain eyeglass lenses and frames from qualified sources other than the Department of Correctional Services upon written approval by the department. Such written approval may be granted in circumstances where the department determines that the Department of Correctional Services cannot perform its obligations under its agreement with the department.

(7) The provisions of this subdivision do not apply to eyeglass lenses and frames provided to recipients of MA who:

(i) are enrolled in managed care programs which receive payment from the MA program on a capitation basis and which include eyeglass lenses and frames as a contract benefit for enrollees; or

(ii) receive eyeglass lenses and frames through clinics which include eyeglass lenses and frames in their MA rates.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.6