Date of Adoption: December 6, 2000.

Purpose: The department has consolidated and clarified rules regarding vision care services in a new chapter. The proposed rules reflect long-standing department policy, are more readable, and comply with the Governor's Executive Order 97-02 on regulatory reform.

     New: Vision care, WAC 388-544-0050, 388-544-0100, 388-544-0150, 388-544-0200, 388-544-0250, 388-544-0300, 388-544-0350, 388-544-0400, 388-544-0450, 388-544-0500, 388-544-0550, and 388-544-0600.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-030 and 388-87-062.

Statutory Authority for Adoption: RCW 74.08.090.

Other Authority: RCW 74.09.510 and 74.09.520.

Adopted under notice filed as WSR 00-17-097 on August 15, 2000.

Changes Other than Editing from Proposed to Adopted Version: WAC 388-544-0100 Client eligibility for vision care services.

     (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 0100):

     (a) Categorically needy (e.g., CNP, CHIP, Children's Health);

     (b) Medically needy (MNP); and

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

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

     (a) Medically indigent (MIP) unless the qualifying emergency medical condition is related to the eye(s);

     (b) Family planning only;...

     WAC 388-544-0150 Requirements for vision care providers.

     (1) The following providers...

     (a) Ophthalmologists/MD or DO;

     (b) Optometrists; and

     (c) Opticians;.

     WAC 388-544-0200 Vision care services MAA covers without MAA's prior authorization.

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

     (a) When the client's condition in both eyes is stable as defined in WAC 388-544-0050 "Stable Visual Condition," and when the...

     (b) MAA covers one pair of back-up eyeglasses when contact lenses are medically necessary and they are the client's primary visual correction...

     (4) MAA covers medically necessary gas permeable or daily-wear-soft contact lenses...

     (5) MAA covers medically necessary therapeutic contact bandage lenses...

     (7) MAA covers medically necessary ocular orthotics/prosthetics...

     (8) MAA covers the following surgeries when medically necessary and when performed by a physician (M.D.) or Osteopathic physician (D.O.) licensed per RCW 18.57 or RCW 18.71 who is qualified to perform such surgeries:...

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

     (9) MAA considers all requests for vision care services not listed as covered in this section or where requested services exceed stated limitations. MAA considers such requests under WAC 388-501-0165.

     WAC 388-544-0250 Vision care services MAA does not cover without MAA's prior authorization.

     (1) MAA evaluates a request for any service that is listed as noncovered in this chapter under the provisions of WAC 388-501-0165.

     (2) MAA evaluates a request for a service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0550, under the provisions of WAC 388-501-0165 which relate to medical necessity.

     (3) MAA evaluates a request for a covered service that is subject to limitation(s) or other restriction(s), and approves such a service beyond those specific limitations or restrictions when the service is medically necessary, under the standards for covered services in WAC 388-501-0165.

     (4) The vision care services that MAA does not cover without MAA's prior authorization include, but are not limited to:...

     (i) Lens replacements for a refractive change which is unstable when the client does not have a "stable visual condition" as defined in WAC 388-544-0050 (see WAC 388-544-0350 (1));...

     (p) Strabismus surgery for a client nineteen eighteen years of age or older unless the client meets MAA's established prior authorization criteria for correctable double vision;

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

     WAC 388-544-0300 Eyeglass frames and service.

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

     WAC 388-544-0350 Eyeglass lenses and service.

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

     (a) The condition requiring correction is a "stable visual condition" as defined in WAC 388-544-0050; and

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

     (1)(2) MAA covers the following types of medically necessary eyeglass lenses:...

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

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

     (b) Both the eye condition and the treatment have stabilized as defined in WAC 388-544-0050 "stable visual condition";

     WAC 388-544-0400 Contact lenses and services.

     (7) MAA covers contact lenses when:

     (a) The client has high anisometropia (the eyes have refractive errors that differ, left to right, by plus or minus 3 diopters or greater); and

     (b) Eyeglasses cannot reasonably correct the refractive errors.

     WAC 388-544-0550 Cataract surgery.

     (1) MAA covers cataract surgery when: (a) iIt is included in the scope of care for the client's medical program; (b) It is medically necessary; and (c) tThe provider clearly documents the need in the client's record. (2) MAA considers the surgery medically necessary when the client has:

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

     (2)(b) One or more of the following conditions:

     (a)(i) Dislocated or subluxated lens;

     (b)(ii) Intraocular foreign body;

     (c)(iii) Ocular trauma;

     (d)(iv) Phacogenic glaucoma;

     (e)(v) Phacogenic uveitis; or

     (f)(vi) Phacoanaphylactic endopthalmitis.

     (3) MAA covers cataract surgery as a nonemergent procedure under any of its medical coverage programs, unless the client is diagnosed as being statutorily blind as defined in WAC 388-544-0350 (10)(b). If the client is blind, the need for cataract surgery is emergent and the cataract surgery is covered by MAA, even if the client is eligible only for medically indigent coverage (MIP).

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 12, Amended 0, Repealed 2.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 12, Amended 0, Repealed 2.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 12, Amended 0, Repealed 2. Effective Date of Rule: Thirty-one days after filing.

December 6, 2000

Marie Myerchin-Redifer, Manager

Rules and Policies Assistance Unit

     "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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     (a) Categorically needy (e.g., CNP, CHIP, children's health);

     (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) unless the qualifying emergency medical condition is related to the eye(s);

     (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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     (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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     (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 medically necessary eyeglasses (frames and/or lenses as needed) according to the following:

     (a) When the client's condition in both eyes is stable as defined in WAC 388-544-0050, Stable visual condition, 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 medically necessary and they 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 medically necessary gas permeable or daily-wear-soft contact lenses per WAC 388-544-0400.

     (5) MAA covers medically necessary 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 medically necessary ocular orthotics/prosthetics per WAC 388-544-0500.

     (8) MAA covers the following surgeries:

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

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

     (9) MAA considers all requests for vision care services not listed as covered in this section or where requested services exceed stated limitations. MAA considers such requests under WAC 388-501-0165.

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     (2) MAA evaluates a request for a service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0550, under the provisions of WAC 388-501-0165 which relate to medical necessity.

     (3) MAA evaluates a request for a covered service that is subject to limitation(s) or other restriction(s), and approves such a service beyond those specific limitations or restrictions when the service is medically necessary, under the standards for covered services in WAC 388-501-0165.

     (4) The vision care services that MAA does not cover without MAA's prior authorization 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 when the client does not have a stable visual condition as defined in WAC 388-544-0050 (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 eighteen years of age or older, unless the client meets MAA's established prior authorization criteria for correctable double vision;

     (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.

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     (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 the materials in the available eyeglass frames, MAA covers the cost of coating the contract eyeglass frames to make the frames 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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     (a) The condition requiring correction is a stable visual condition as defined in WAC 388-544-0050; and

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

     (2) MAA covers the following types of medically necessary 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 lenses are medically necessary and the size and style of the required lens(es) meet MAA's contract requirements.

     (4) MAA covers medically necessary 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 as defined in WAC 388-544-0050, Stable visual condition; 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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     (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).

     (7) MAA covers contact lenses when:

     (a) The client has high anisometropia (the eyes have refractive errors that differ, left to right, by plus or minus three diopters or greater); and

     (b) Eyeglasses cannot reasonably correct the refractive errors.

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     (1) Eye injury; or

     (2) Eye surgery.

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     (1) An ophthalmologist;

     (2) An ocularist; or

     (3) An optometrist who specializes in orthotics.

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     (a) It is included in the scope of care for the client's medical program;

     (b) It is medically necessary; and

     (c) The provider clearly documents the need in the client's record.

     (2) MAA considers the surgery medically necessary when the client has:

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

     (b) One or more of the following conditions:

     (i) Dislocated or subluxated lens;

     (ii) Intraocular foreign body;

     (iii) Ocular trauma;

     (iv) Phacogenic glaucoma;

     (v) Phacogenic uveitis; or

     (vi) Phacoanaphylactic endopthalmitis.

     (3) MAA covers cataract surgery as a nonemergent procedure under any of its medical coverage programs, unless the client is diagnosed as being statutorily blind as defined in WAC 388-544-0350 (10)(b). If the client is blind, the need for cataract surgery is emergent and the cataract surgery is covered by MAA, even if the client is eligible only for medically indigent coverage (MIP).

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     (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 388-87-062

Payment -- Eyeglasses and examinations.

2510.1
REPEALER

     The following section of the Washington Administrative Code is repealed:

WAC 388-86-030

Vision care.

© Washington State Code Reviser's Office