Original Notice.

Preproposal statement of inquiry was filed as WSR 98-01-167.

Title of Rule: New chapter 388-544 WAC, Vision care; and repealing WAC 388-86-030 Vision care and 388-87-062 Payments -- Eyeglasses and examinations.

Purpose: The department is establishing a new chapter to incorporate and consolidate rules regarding vision care services. The proposed rules reflect long-standing department policy. They are more readable, and they comply with the Governor's Executive Order 97-02 on regulatory reform. The proposed rules have been reviewed in consultation with the regulated parties. WAC 388-86-030 and 388-87-062 are being repealed in order to avoid duplication.

Statutory Authority for Adoption: RCW 74.08.090.

Statute Being Implemented: RCW 74.09.510, 74.09.520, and 74.08.090.

Summary: The department is rewriting these rules in order to consolidate all rules on vision care services into a single chapter and ensure that department policy is reflected in rule. The proposed rules clarify vision care-related terms, client eligibility for services, provider requirements, covered and noncovered services, specific coverage limitations, and reimbursement policy.

Reasons Supporting Proposal: To ensure that department rules reflect current and accurate department policy, to eliminate confusion by consolidating related rules and to comply with the Governor's Executive Order 97-02 on regulatory reform.

Name of Agency Personnel Responsible for Drafting: L. Mike Freeman, MAA/RIP, P.O. Box 45533, Olympia, WA 98504, (360) 725-1350; and Implementation: Joan Baumgartner, MD, MAA, P.O. Box 45500, Olympia, WA 98504, (360) 725-1585.

Name of Proponent: Department of Social and Health Services, Medical Assistance Administration, governmental.

Rule is not necessitated by federal law, federal or state court decision.

Explanation of Rule, its Purpose, and Anticipated Effects: The rule defines terms associated with vision care services, clarifies who is eligible for MAA-reimbursed vision care services, states MAA requirements for vision care providers, what vision care services MAA covers and does not cover, specific coverage limitations, and reimbursement policy.

     The purpose is to make MAA policy clear.

     The anticipated effect is to promote a clearer understanding of MAA policy and practice.

Proposal Changes the Following Existing Rules: The rules proposed above repeal existing rules and establish a new WAC chapter for vision care services. The proposed rules reflect the program's operational polices and provide greater detail into long-standing policy and practice.

No small business economic impact statement has been prepared under chapter 19.85 RCW. MAA reviewed the proposed rules and concluded that the impact of the proposed rules will not place "a more than minor impact on businesses." MAA program managers held discussions with service providers to discuss the impact of these clarifications. They have agreed with MAA's assessment of the impacts.

RCW 34.05.328 applies to this rule adoption. MAA has determined that the proposed rules qualify as "significant legislative rules." Therefore, MAA has analyzed the probable costs and the probable benefits of the proposed rules, taking into account both the qualitative and quantitative benefits and costs. MAA's analysis revealed that no new costs will be imposed, existing costs will not be increased, and benefits to businesses will not be decreased. The analysis may be obtained from Joan Baumgartner, MD, MAA, P.O. Box 45500, Olympia, WA 98504, (360) 725-1585.

Hearing Location: Blake Office Building East, 4500 10th Avenue S.E., Rose Room, Lacey, WA 98503, on October 3, 2000, at 10:00 a.m.

Assistance for Persons with Disabilities: Contact Kelly Cooper, Rules Coordinator, by September 26, 2000, phone (360) 664-6094, TTY (360) 664-6178, e-mail coopeKD@dshs.wa.gov.

Submit Written Comments to: Identify WAC Numbers, Kelly Cooper, Rules Coordinator, Rules and Policies Assistance Unit, P.O. Box 45850, Olympia, WA 98504-5850, fax (360) 664-6185, by October 3, 2000.

Date of Intended Adoption: Not sooner than October 4, 2000.

August 8, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

The following definitions and abbreviations and those found in WAC 388-500-0005 apply to this chapter. Defined words and phrases are bolded the first time they are used in the text. Unless otherwise defined in this chapter, medical terms are used as commonly defined within the scope of professional medical practice in the state of Washington.

     "Stable visual condition" means that a client's eye condition has no acute disease or injury; or the client has reached a point after any acute disease or injury where the variation in need for refractive correction has diminished or steadied. The client's vision condition has stabilized to the extent that eyeglasses or contact lenses are appropriate and that any prescription for refractive correction is likely to be sufficient for one year or more.

     "Visual field exams or testing" means a process to determine defects in the field of vision and tests the function of the retina, optic nerve and optic pathways. The process may include simple confrontation to increasingly complex studies with sophisticated equipment.

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(1) The medical assistance administration (MAA) covers vision care services for clients eligible for the following "scope-of-care" designations (see WAC 388-529-0200):

     (a) Categorically needy (CNP);

     (b) Medically needy (MNP); and

     (c) Medical care services (MCS or GAU/ADATSA).

     (2) MAA does not cover vision care services for clients with the following program designations:

     (a) Medically indigent (MIP);

     (b) Family planning only;

     (c) Any program designated "emergency medical only"; or

     (d) Any other program that does not meet the conditions of subsection (1) of this section.

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(1) The following providers are eligible to enroll/contract with MAA to provide and bill for vision care services furnished to eligible clients:

     (a) Ophthalmologists/MD or DO.

     (b) Optometrists; and

     (c) Opticians;

     (2) Enrolled/contracted eye care providers must:

     (a) Meet the requirements in chapter 388-502 WAC;

     (b) Provide only those services that are within the scope of the provider's license; and

     (c) Obtain all hardware and contact lenses from MAA's contract suppliers.

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(1) MAA covers medically necessary eye examinations, refractions, eyeglasses (frames and/or lenses), and fitting fees as follows:

     (a) For clients who are asymptomatic and are twenty-one years of age or older, once every twenty-four months;

     (b) For clients who are asymptomatic and are twenty years of age or younger, once every twelve months;

     (c) For adults or children who are identified on the medical assistance identification card (MAID) as being developmentally disabled, once every twelve months;

     (d) For clients on medication that affects vision, as often as is medically necessary as documented by the provider;

     (e) For clients for whom the provider is diagnosing or treating a medical condition that has symptoms of vision problems or disease, as often as medically necessary. The provider must document the diagnosis and/or treatment in the client's record to justify the frequency of examinations and other services.

     (2) MAA covers medically necessary visual field exams for the diagnosis and treatment of abnormal signs, symptoms or injuries. MAA does not reimburse visual field exams that are done by simple confrontation. Documentation in the record must show all of the following:

     (a) The extent of the testing;

     (b) Why the testing was reasonable and necessary for the client; and

     (c) The medical basis for the frequency of testing.

     (3) MAA covers eyeglasses (frames and/or lenses as needed) according to the following:

     (a) When the client's condition in both eyes is stable, and when the minimum correction need is documented and meets one of the following:

     (i) Sphere power equal to or greater than plus or minus 0.50 diopters;

     (ii) Astigmatism power equal to or greater than plus or minus 0.50 diopters; or

     (iii) A combination of spherical power and astigmatic power that is equal to or greater than a spherical equivalent of plus or minus 0.75 diopters (the spherical equivalent means one half cylinder added algebraically to the sphere correction).

     (b) MAA covers one pair of back-up eyeglasses when contact lenses are the client's primary visual correction aid as described in WAC 388-544-0400. MAA limits back-up eye glasses as follows (also see WAC 388-544-0250 (1)(e)):

     (i) For clients twenty years of age or younger, once every two years;

     (ii) For clients twenty-one years of age and older, once every six years; or

     (iii) When MAA agrees in advance to the medical necessity and the service is provided consistent with the limitations included in MAA's authorization.

     (4) MAA covers gas permeable or daily-wear-soft contact lenses per WAC 388-544-0400.

     (5) MAA covers therapeutic contact bandage lenses per WAC 388-544-0450.

     (6) MAA covers all hyperopic prescriptions for clients who are twenty years of age or younger and who have a diagnosis of "accommodative esotropia" or any strabismus correction. These clients are not subject to the requirements in subsection (3)(a) of this section (stable eye condition and minimum correction need).

     (7) MAA covers ocular orthotics/prosthetics per WAC 388-544-0500.

     (8) MAA covers the following surgeries:

     (a) Strabismus surgery for clients eighteen years of age and younger; and

     (b) Cataract surgery per WAC 388-544-0550.

     (9) MAA considers all requests for vision care services under WAC 388-501-0165.

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(1) The vision care services that MAA does not cover include, but are not limited to:

     (a) Any of the following types of contact lenses:

     (i) Disposable lenses;

     (ii) Extended wear soft lenses; or

     (iii) Extended wear soft toric lenses.

     (b) Any eye service or hardware that MAA considers not to be medically necessary;

     (c) Any eyeglasses (frames and/or lenses) or contact lenses upgraded at private expense to avoid MAA's contract limitations (e.g., frames that are not available through MAA's contract or noncontract frames or lenses for which the client or other person pays the difference between MAA's payment and the total cost) (see WAC 388-544-0300(7) and 388-544-0350(3));

     (d) Bifocal additions to eyeglasses with bifocal correction of less than 1.0 diopter;

     (e) Both eyeglasses and contact lenses in a two-year period for any client (see WAC 388-544-0200 (3)(b) for backup eyeglass exceptions);

     (f) Eyeglasses or contact lenses when the prescribed need does not meet the minimum corrections described in this chapter;

     (g) Eyeglasses or contact lenses when the prescription is over two years old;

     (h) Group vision screening for eyeglasses;

     (i) Lens replacements for a refractive change which is unstable (see WAC 388-544-0350(1));

     (j) Other vision services or hardware for persons enrolled in MAA's managed care program (Healthy Options) when the requirements of that program have not been met;

     (k) Orthoptics and visual training therapy;

     (l) Plano lenses (no refractive correction) for both eyes, except as provided in WAC 388-544-0350 (12)(a));

     (m) Progressive additions lenses, including blended bifocals;

     (n) Refractive surgery of any type (e.g., Radial Keratotomy or laser resurfacing);

     (o) Separate charges for eye exams conducted in combination with emergency or operating room procedures;

     (p) Strabismus surgery for a client nineteen years of age or older;

     (q) Sunglasses or colored/tinted lenses requested for cosmetic or other nonmedical reasons;

     (r) Two pairs of eyeglasses (e.g., instead of one pair of multifocals); and

     (s) Other services or hardware that do not meet the requirements in this chapter.

     (2) MAA considers all requests for vision care service under WAC 388-501-0165.

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(1) The medical assistance administration (MAA) covers pre-approved eyeglass frames through MAA's contracted supplier.

     (2) MAA covers eyeglass frames, with specific time limits, for eligible clients who:

     (a) Are twenty-one years of age and older, once every twenty-four months;

     (b) Are twenty years of age and younger, once every twelve months;

     (c) Are identified on the MAID card as being developmentally disabled (adults or children), once every twelve months;

     (d) Have been unable to adjust to contact lenses after thirty days. The provider must document the client's inability to adjust and the client must return the contact lenses to the provider.

     (3) MAA covers preapproved special frames called "durable and flexible frames" through MAA's contracted supplier when a client:

     (a) Is diagnosed with a seizure disorder that results in frequent falls; or

     (b) Has a medical condition that has resulted in two or more broken eyeglass frames in a twelve-month period (e.g., Tourette's syndrome).

     (4) MAA covers replacement eyeglass frames that have been lost, broken, or stolen:

     (a) For adults, only with MAA's prior authorization (see WAC 388-501-0165); and

     (b) Without MAA's prior authorization for clients who are either:

     (i) Twenty years of age or younger; or

     (ii) Identified on the MAID care as being developmentally disabled, regardless of the client's age.

     (5) MAA covers incidental repairs to a client's eyeglass frames when both of the following apply:

     (a) The repair or adjustment is not typically provided to the public at no cost; and

     (b) The cost of the repair does not exceed MAA's cost for replacement frames. MAA's reimbursement for repairs does not exceed its payment level for replacement frames.

     (6) If the client has a medically diagnosed allergy to plastic, MAA covers the coating of contract eyeglass frames to make them nonallergenic.

     (7) MAA does not allow clients to upgrade eyeglass frames and pay only the upgrade costs in order to avoid MAA's contract limitations (see WAC 388-544-0250 (1)(c) and 388-544-0350(3)).

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(1) The medical assistance administration (MAA) covers eyeglass lenses to correct a client's vision if both of the following apply:

     (a) The condition requiring correction is stable; and

     (b) The prescription is less than two years old.

     (2) MAA covers the following types of eyeglass lenses:

     (a) Single vision lenses;

     (b) Round or flat top D-style bifocals;

     (c) Trifocals that are twenty-five or twenty-eight millimeters;

     (d) Slab-off and prism lenses (including Fresnel lenses); and

     (e) Glass lenses fifty-four millimeters and smaller.

     (3) For clients who own their own serviceable eyeglass frames and request lenses only, MAA covers these requests if the size and style of the required lens(es) meet MAA's contract requirements.

     (4) MAA covers lens replacements without regard to time limits when (a), (b), and (c) of this subsection apply:

     (a) One of the following caused the vision change:

     (i) Eye surgery;

     (ii) The effect(s) of prescribed medication; or

     (iii) One or more diseases;

     (b) Both the eye condition and the treatment have stabilized; and

     (c) The lens correction has at least one diopter difference between the old and new prescriptions.

     (5) MAA covers lens replacement for lost or broken lenses according to the same standards as frames in WAC 388-544-0300 (2) and (4).

     (6) MAA allows bifocal lenses to be replaced with single vision lenses or trifocal lenses to be replaced with bifocals or single vision lenses when all of the following apply:

     (a) A client has attempted to adjust to the bifocals or trifocals for at least sixty days;

     (b) The client is unable to make the adjustment; and

     (c) The bifocal or trifocal lenses being replaced are returned to the provider.

     (7) MAA covers plastic executive bifocals or trifocals only for clients who are diagnosed with:

     (a) Accommodative esotropia; or

     (b) Strabismus.

     (8) MAA covers high index lenses when the client requires a refractive correction of plus or minus eight diopters or greater.

     (9) MAA covers the tinting of plastic lenses when:

     (a) The client's medical need is diagnosed and documented as a chronic eye condition causing photophobia; and

     (b) The tinting is done by MAA's contracted lens supplier.

     (10) MAA covers glass photochromatic lenses when the client's medical need is diagnosed and documented as related to either (a) or (b) of this subsection :

     (a) Ocular albinism; or

     (b) Blindness, defined as:

     (i) Visual acuity for distance vision of twenty/two hundred or worse in the better eye with best correction; or

     (ii) A limitation of the client's visual field (widest diameter) subtending an angle of less than twenty degrees from central.

     (11) MAA covers treating plastic lenses for scratch resistance only when the client is either:

     (a) Twenty years or age or younger; or

     (b) Identified on the MAID card as being developmentally disabled.

     (12) MAA covers polycarbonate lenses when a client is any of the following:

     (a) Blind in one eye as defined in subsection (10) of this section and the client needs protection for the other eye, regardless of whether a vision correction is required;

     (b) Twenty years of age or younger and diagnosed with strabismus or amblyopia; or

     (c) Identified on the MAID card as being developmentally disabled.

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(1) The medical assistance administration (MAA) covers gas permeable or daily wear soft contact lenses as the client's primary refractive correction method if a client has a vision correction of plus or minus 6.0 diopters or greater.

     (2) MAA does not cover contact lenses if the client's ocular condition makes it medically inadvisable (contraindicated) for the client to use contact lenses.

     (3) MAA covers contact lens replacements:

     (a) Once every twelve months for normal replacement; or

     (b) When the contact lenses are lost or damaged, with the following limitations:

     (i) The prescription must not be over seventeen months old; and

     (ii) The date of dispensing for the lost or damaged lenses must not be within the past eleven months.

     (4) MAA does not cover contact lenses for a patient who has received MAA-covered eyeglasses within the past two years unless the provider:

     (a) Documents the medical necessity to MAA's satisfaction; and

     (b) Receives prior authorization from MAA.

     (5) MAA covers soft toric contact lenses (daily wear) for clients with astigmatism requiring a correction equal to or greater than one diopter (plus or minus).

     (6) MAA covers lenticular, aspheric and myodisc contact lenses when the client has one or more of the following:

     (a) Multiple cataract surgeries on the same eye;

     (b) Aphakia;

     (c) Keratoconus with refractive error of plus or minus ten diopters; or

     (d) Corneal softening (e.g., bullous keratopathy).

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The medical assistance administration (MAA) covers therapeutic contact bandage lenses only when needed immediately after:

     (1) Eye injury; or

     (2) Eye surgery.

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The medical assistance administration (MAA) covers ocular prosthetics which are medically necessary and provided by any of the following:

     (1) An ophthalmologist;

     (2) An ocularist; or

     (3) An optometrist who specializes in orthotics.

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MAA covers cataract surgery when it is medically necessary and the provider clearly documents the need in the client's record. MAA considers the surgery medically necessary when the client has:

     (1) Correctable visual acuity in the affected eye at 20/50 or worse, as measured on the Snellen test chart; or

     (2) One or more of the following conditions:

     (a) Dislocated or subluxated lens;

     (b) Intraocular foreign body;

     (c) Ocular trauma;

     (d) Phacogenic glaucoma;

     (e) Phacogenic uveitis; or

     (f) Phacoanaphylactic endopthalmitis.

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(1) The medical assistance administration (MAA) covers one hundred percent of the MAA contract price for eyeglass frames, lenses, and contact lenses when these items are obtained through MAA's approved contract(s).

     (2) See WAC 388-531-1850 for professional fee payment methodology.

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     The following section of the Washington Administrative Code is repealed:

WAC 388-86-030

Vision care.

2511.1
REPEALER

     The following section of the Washington Administrative Code is repealed:

WAC 388-87-062

Payment -- Eyeglasses and examinations.

© Washington State Code Reviser's Office