WSR 05-13-038

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed June 6, 2005, 4:29 p.m. , effective July 7, 2005 ]


Purpose: This WAC revision updates and clarifies existing policy regarding vision care services; clarifies client and program eligibility and scope of coverage of vision care services; and clarifies payment limitations and incorporates policy changes related to bringing MAA's vision care services program into closer alignment with industry standards and safety.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-544-0200; and amending WAC 388-544-0050, 388-544-0100, 388-544-0150, 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.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.510, and 74.09.520.

Other Authority: 42 C.F.R. 440.120 and 440.225.

Adopted under notice filed as WSR 05-08-092 on April 1, 2005.

Changes Other than Editing from Proposed to Adopted Version: A few spelling errors were fixed. Also, under WAC 388-544-0350(2), the following wording was added (underlined): "MAA allows bifocal lenses to be replaced with single vision or trifocal lenses or trifocal lenses to be replaced with bifocal or single vision lenses when all of the following apply:"

A final cost-benefit analysis is available by contacting Marlene Black, Vision Care, Medical Assistance Administration, Division of Medical Management, P.O. Box 45506, Olympia, WA 98504-5506, phone (360) 725-1577, fax (360) 586-8827, e-mail blackml@dshs.wa.gov.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 2, Amended 11, Repealed 1.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 2, Amended 11, Repealed 1.

Date Adopted: June 1, 2005.

Andy Fernando, Manager

Rules and Policies Assistance Unit

3533.3
NEW SECTION
WAC 388-544-0010   Vision care - general.   (1) The medical assistance administration (MAA) covers the vision care listed in this chapter only, subject to the exceptions, restrictions, and limitations listed in this chapter when they are:

(a) Within the scope of the eligible client's medical care program (see chapter 388-529 WAC); and

(b) Medically necessary as defined in WAC 388-500-0005.

(2) MAA evaluates a request for any service that is listed as noncovered in this chapter under the provisions of WAC 388-501-0160.

(3) MAA evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions when medically necessary, under the standards for covered services in WAC 388-501-0165.

(4) 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.

[]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0050   Vision care - definitions ((for vision care services)).   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.

"Blindness" - A diagnosis of visual acuity for distance vision of twenty/two hundred or worse in the better eye with best correction or a limitation of the client's visual field (widest diameter) subtending an angle of less than twenty degrees from central.

"Conventional soft contact lenses" or "rigid gas permeable contact lenses" - FDA-approved contact lenses that do not have a scheduled replacement (discard and replace with new contacts) plan. The soft lenses usually last one year, and the rigid gas permeable lenses usually last two years. Although some of these lenses are designed for extended wear, MAA generally approves only those lenses that are designed to be worn as daily wear (remove at night).

"Disposable contact lenses" - FDA-approved contact lenses that have a planned replacement schedule (e.g., daily, every two weeks, monthly, quarterly). The contacts are then discarded and replaced with new ones as scheduled. Although many of these lenses are designed for extended wear, MAA generally approves only those lenses that are designed to be worn as daily wear (remove at night).

"Extended wear soft contacts" - Contact lenses that are designed to be worn for longer periods than daily wear (remove at night) lenses. These can be conventional soft contact lenses or disposable contact lenses designed to be worn for several days and nights before removal.

"Hardware" - Eyeglass frames and lenses and contact lenses.

"Specialty contact lens design" - Custom contact lenses that have a more complex design than a standard spherical lens. These specialty contact lenses (e.g., lenticular, aspheric, or myodisc) are designed for the treatment of specific disease processes, such as keratoconus, or are required due to high refractive errors. This definition of specialty contact lens does not include lenses used for surgical implantation.

"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 test((s)) the function of the retina, optic nerve and optic pathways. The process may include simple confrontation to increasingly complex studies with sophisticated equipment.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0050, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0100   Vision care - eligible clients ((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 388-529-0100))) Clients who receive services under the following medical assistance programs are eligible for covered vision care:

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

(b) ((Medically needy (MNP); and)) Categorically needy program - Children's health insurance program (CNP-CHIP);

(c) ((Medical care services (MCS or GAU/ADATSA))) Limited casualty program - medically needy program (LCP-MNP);

(d) General assistance (GA-U/ADATSA) (within Washington state or designated border cities); and

(e) Emergency medical only programs when the services are directly related to an emergency medical condition only.

(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)) Clients who are enrolled in an MAA managed care plan are eligible under fee-for-service for covered vision care services that are not covered by their plan, subject to the provisions of chapter 388-544 WAC and other applicable WAC.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0100, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0150   Vision care - provider requirements ((for vision care providers)).   (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)) 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;

(c) Obtain all hardware and contact lenses for MAA clients from MAA's contracted supplier; and

(d) Return all unclaimed hardware and contact lenses to MAA's contracted supplier using a postage-paid envelope furnished by the contractor.

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

(a) Ophthalmologists;

(b) Optometrists;

(c) Opticians; and

(d) Ocularists.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0150, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0250   Vision care - covered eye services ((MAA does not cover without MAA's prior authorization)) (examinations and refractions).   (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:

(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)) The medical assistance administration (MAA) covers eye examinations and refraction services for asymptomatic clients under the following conditions and limitations, unless the circumstances in subsections (2) or (3) of this section apply:

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

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

(c) For clients with developmental disabilities, regardless of age, once every twelve months.

(2) MAA covers eye examinations and refraction services as often as medically necessary when:

(a) The provider is diagnosing or treating the client for a medical condition that has symptoms of vision problems or disease; or

(b) The client is on medication that affects vision.

(3) MAA covers eye examinations/refractions outside the time limitations in subsection (1) of this section when the eye examination/refraction is necessary due to lost or broken eyeglasses/contacts. In this situation, MAA does not require authorization for children. To receive payment for an adult client, providers must:

(a) Follow the expedited prior authorization process; and

(b) Document the following in the client's file:

(i) The eyeglasses or contacts are lost or broken; and

(ii) The last examination was at least eighteen months ago.

(4) MAA covers visual field exams for the diagnosis and treatment of abnormal signs, symptoms, or injuries. To receive payment, providers must document all of the following in the client's record:

(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.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0250, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0300   ((Eyeglass frames and service)) Vision care - covered eyeglasses (frames and/or lenses) and repair services.   (1) The medical assistance administration (MAA) covers ((pre-approved eyeglass frames through MAA's contracted supplier)) eyeglasses for asymptomatic clients:

(a) Under the following conditions and limitations:

(i) For clients twenty-one years of age or older, once every twenty-four months;

(ii) For clients twenty years of age or younger, once every twelve months; or

(iii) For clients with developmental disabilities, regardless of age, once every twelve months.

(b) When:

(i) The client has a stable visual condition;

(ii) The client's treatment is stabilized;

(iii) The prescription is less than eighteen months old; and

(iv) One of the following minimum correction needs in a least one eye is documented in the client's file:

(A) Sphere power equal to, or greater than, plus or minus 0.50 diopter;

(B) Astigmatism power equal to, or greater than, plus or minus 0.50 diopter; or

(C) Add power equal to, or greater than, 1.0 diopter for bifocals and trifocals.

(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)) eyeglasses and/or lenses for clients who are twenty years of age or younger with a diagnosis of accommodative esotropia or any strabismus correction. In this situation, the client is not subject to the requirements in subsection (1)(b) of this section.

(3) MAA covers ((preapproved special)) selected frames called "durable ((and))" or "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 diagnosed medical condition that has ((resulted in)) contributed to two or more broken eyeglass frames in a twelve-month period (((e.g., Tourette's syndrome))). To receive payment, providers must follow the expedited prior authorization process.

(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)) the cost of coating contract eyeglass frames to make the frames nonallergenic if the client has a medically diagnosed and documented allergy to the materials in the available eyeglass frames.

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

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

(b) The contractor's one year warranty period has expired; and

(c) 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)) MAA covers replacement eyeglass frames and/or lenses that have been lost or broken. To receive payment, providers must follow the expedited prior authorization process for clients twenty-one years of age and older. MAA does not require authorization for clients who are twenty years of age and younger or for clients with developmental disabilities, regardless of age. (See WAC 388-544-0350 for additional coverage of lens replacement.)

(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)))) covers one pair of back-up eyeglasses when contact lenses are medically necessary and the contact lenses are the client's primary visual correction aid as described in WAC 388-544-0400(1). MAA limits coverage for back-up eyeglasses as follows:

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

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

(c) For clients with developmental disabilities, regardless of age, once every two years.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0300, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0350   Vision care - covered plastic scratch-resistant eyeglass lenses and services.   (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.

(2) MAA covers)) the following ((types of medically necessary)) plastic scratch-resistant eyeglass lenses:

(a) Single vision lenses;

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

(c) Flat top trifocals ((that are twenty-five or twenty-eight millimeters)); and

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

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

(2) MAA allows bifocal lenses to be replaced with single vision or trifocal lenses or trifocal lenses to be replaced with bifocal 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.

(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)) MAA covers high index lenses for clients who require one of the following in at least one eye:

(a) A spherical refractive correction of plus or minus eight diopters or greater; or

(b) A cylinder correction of plus or minus eight diopters or greater.

To receive payment, providers must follow the expedited prior authorization process.

(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)) the tinting of plastic lenses through MAA's contracted lens supplier. The client's medical need must be diagnosed and documented as one or more of the following chronic (expected to last longer than three months) eye conditions causing photophobia:

(a) Blindness;

(b) Chronic corneal keratitis;

(c) Chronic iritis, iridocyclitis;

(d) Diabetic retinopathy;

(e) Fixed pupil;

(f) Glare from cataracts;

(g) Macular degeneration;

(h) Migraine disorder;

(i) Ocular albinism;

(j) Optic atrophy and/or optic neuritis;

(k) Rare photo-induced epilepsy conditions; or

(l) Retinitis pigmentosa.

(5) MAA covers plastic photochromatic lenses when the client's medical need is diagnosed as relating to ocular albinism or retinitis pigmentosa.

(6) MAA covers polycarbonate lenses as follows:

(a) For clients who are blind in one eye and need protection for the other eye, regardless of whether a vision correction is required;

(b) Infants and toddlers with motor ataxia;

(c) For clients twenty years of age or younger who are diagnosed with strabismus or amblyopia; or

(d) For clients with developmental disabilities.

(7) MAA covers requests for lenses only when the client owns frames not purchased by MAA, when:

(a) The eyeglass frames are serviceable (MAA and MAA's contractor do not accept responsibility for these frames); and

(b) The size and style of the required lenses meet MAA's contract requirements.

(8) MAA covers replacement lenses as follows:

(a) Due to lost or broken lenses according to WAC 388-544-0300(6); and

(b) Due to refractive changes, without regard to time limits, when caused by one of the following:

(i) Eye surgery, the effects of prescribed medication, or one or more diseases affecting vision. In this case, all of the following must be documented in the client's file:

(A) The client has a stable visual condition;

(B) The client's treatment is stabilized;

(C) The lens correction must have a 1.0 or greater diopter change between the sphere or cylinder correction in at least one eye; and

(D) The previous and new refraction.

(ii) Headaches, blurred vision, or difficulty with school or work. In this case, all of the following must be documented in the client's file:

(A) Copy of current prescription (less than eighteen months old);

(B) Date of last dispensing, if known;

(C) Absence of a medical condition that is known to cause temporary visual acuity changes (e.g., diabetes, pregnancy, etc.); and

(D) A refractive change of at least .75 diopter or greater between the sphere or cylinder correction in at least one eye.

(c) To receive payment for replacement lenses, providers must follow the expedited prior authorization process.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0350, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0400   Vision care - covered contact lenses and services.   (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).

(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)) the following types of contact lenses as the client's primary refractive correction method when a client has a spherical correction of plus or minus 6.0 diopters or greater in at least one eye. In order to qualify for the spherical correction, the prescription may be from either the glasses or the contact lenses prescriptions and/or written in either "minus cyl" or "plus cyl" form. See subsection (2) of this section for exception to the plus or minus 6.0 diopter criteria.

(a) Conventional soft contact lenses or rigid gas permeable contact lenses that are prescribed for daily wear; or

(b) Disposable contact lenses that are prescribed for daily wear and have a monthly or quarterly planned replacement schedule, as follows:

(i) Twelve pairs of monthly replacement contact lenses; or

(ii) Four pairs of three-month replacement contact lenses.

(2) For clients diagnosed with high anisometropia, MAA covers the contact lenses in subsection (1) of this section when the client's refractive error difference between the two eyes is plus or minus 3.0 diopters and eyeglasses cannot reasonably correct the refractive errors.

(3) A client who qualifies for contact lenses as the primary refractive correction method must choose one style of contact lenses from those listed in subsection (1) of this section for each twelve-month period of coverage.

(4) MAA covers soft toric contact lenses for clients with astigmatism requiring a cylinder correction of plus or minus 1.0 diopter in at least one eye and the client also meets the spherical correction listed in subsection (1) of this section.

(5) MAA covers specialty contact lens designs for clients who are diagnosed with one or more of the following:

(a) Aphakia;

(b) Keratoconus; or

(c) Corneal softening.

(6) MAA covers replacement contact lenses as follows:

(a) Once every twelve months for lost or damaged contact lenses; or

(b) As often as medically necessary when all of the following apply:

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

(A) Eye surgery;

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

(C) One or more diseases affecting vision.

(ii) The client has a stable visual condition;

(iii) The client's treatment is stabilized; and

(iv) The lens correction has a 1.0 or greater diopter change in at least one eye between the sphere or cylinder correction. The previous and new refraction must be documented in the client's record.

(c) To receive payment for adults, providers must follow the expedited prior authorization process. Prior authorization is not required for children or for clients with developmental disabilities.

(7) MAA covers therapeutic contact bandage lenses only when needed immediately after eye injury or eye surgery.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0400, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0450   ((Therapeutic contact bandage lenses)) Vision care - prior authorization.   ((The medical assistance administration (MAA) covers therapeutic contact bandage lenses only when needed immediately after:))

(1) ((Eye injury; or)) The medical assistance administration (MAA) requires a provider to follow the prior authorization and expedited prior authorization (EPA) process for certain vision care services as identified in this chapter.

(2) ((Eye surgery)) For prior authorization (PA), a provider must call or fax MAA using the appropriate telephone or fax number listed in MAA's published vision care billing instructions.

(3) For expedited prior authorization (EPA), a provider must create an EPA number. The process and criteria used to create this authorization number are explained in MAA's published vision care billing instructions. The EPA number must be used when the provider bills MAA.

(4) MAA denies payment for vision care submitted without the required PA or EPA number, or the appropriate diagnosis or procedure code as indicated by the EPA number.

(5) Upon request, a provider must provide documentation to MAA showing how the client's condition met the criteria for PA or EPA.

(6) MAA may recoup any payment made to a provider under this chapter if MAA later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC 388-502-0100 (1)(c).

(7) When a client's situation does not meet the EPA criteria for vision care, or a requested service or item exceeds the limit indicated in this chapter, a provider must follow the requirements of WAC 388-501-0165.

(8) MAA evaluates a request for any service that is listed as noncovered in this chapter under the provisions of WAC 388-501-0160.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0450, filed 12/6/00, effective 1/6/01.]


NEW SECTION
WAC 388-544-0475   Vision care - noncovered services, eyeglasses, and contact lenses.   The medical assistance administration (MAA) does not cover the following:

(1) Executive style eyeglass lenses;

(2) Bifocal contact lenses;

(3) Daily and two week disposable contact lenses;

(4) Extended wear soft contact lenses, except when used as therapeutic contact bandage lenses or for aphakic clients;

(5) Services for cosmetic purposes only;

(6) Glass lenses including those that darken when exposed to light;

(7) Group vision screening for eyeglasses;

(8) Nonglare or anti-reflective lenses;

(9) Orthoptics and visual training therapy;

(10) Progressive lenses;

(11) Refractive surgery of any type that changes the eye's refractive error. The intent of the refractive surgery procedure is to reduce or eliminate the need for eyeglass or contact lens corrections. This does not include intraocular lens implantation following cataract surgery.

(12) Sunglasses and accessories that function as sunglasses (e.g., "clip-ons");

(13) Upgrades 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).

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AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0500   Vision care - ocular prosthetics.   The medical assistance administration (MAA) covers medically necessary ocular prosthetics ((which are medically necessary and)) when provided by any of the following:

(1) An ophthalmologist;

(2) An ocularist; or

(3) An optometrist who specializes in orthotics.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0500, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0550   ((Cataract)) Vision care - surgery.   (1) The medical assistance administration (MAA) covers cataract surgery when:

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

(b) It is medically necessary as defined in subsection (2) of this section; and

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

(2) MAA considers ((the)) cataract surgery to be 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; or

(vii) Increased ocular pressure in a person who is blind and is experiencing ocular pain.

(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))) strabismus surgery as follows:

(a) For clients seventeen years of age and younger, when medically necessary. The provider must clearly document the need in the client's record.

(b) For clients eighteen years of age and older when:

(i) The client has double vision; and

(ii) The surgery is not performed for cosmetic reasons.

(c) To receive payment for clients eighteen years of age and older, providers must follow MAA's expedited prior authorization process listed in WAC 388-544-0450. MAA does not require authorization for clients seventeen years of age and younger.

(4) MAA covers blepharoplasty or blepharoptosis surgery for noncosmetic reasons when:

(a) The excess upper eyelid skin impairs the vision by blocking the superior visual field; and

(b) The vision is blocked to within ten degrees of central fixation using a central visual field test.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0550, filed 12/6/00, effective 1/6/01.]


AMENDATORY SECTION(Amending WSR 01-01-010, filed 12/6/00, effective 1/6/01)

WAC 388-544-0600   Vision care - payment methodology.   (1) In order to receive payment, vision care providers must bill the medical assistance administration (MAA) according to the conditions of payment under WAC 388-502-0020 (1)(a) through (c) and WAC 388-502-0100 and MAA's published billing instructions.

(2) ((The medical assistance administration (MAA))) 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))) (3) See WAC 388-531-1850 for professional fee payment methodology.

[Statutory Authority: RCW 74.08.090, 74.09.510 and 74.09.520. 01-01-010, 388-544-0600, filed 12/6/00, effective 1/6/01.]


REPEALER

     The following section of the Washington Administrative Code is repealed:
WAC 388-544-0200 Vision care services MAA covers without MAA's prior authorization.

Washington State Code Reviser's Office