WSR 05-14-121

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed July 1, 2005, 4:23 p.m. ]

Original Notice.

Exempt from preproposal statement of inquiry under RCW 34.05.310(4).

Title of Rule and Other Identifying Information: Amending WAC 388-544-0350 Vision care -- Covered plastic scratch-resistant eyeglass lenses and services.

Hearing Location(s): Blake Office Park East (behind Goodyear Courtesy Tire), Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503, on August 9, 2005, at 10:00 a.m.

Date of Intended Adoption: Not earlier than August 10, 2005.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., August 9, 2005.

Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by August 5, 2005, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: This proposal corrects subsection (3)(b) that contained an error when the rule was amended recently, replacing the word "eight" with "three." Subsection (3)(b) would now read, "a cylinder correction of plus or minus three diopters or greater."

Reasons Supporting Proposal: The correction benefits eligible vision clients, and helps assure that eligible clients receive needed medical services.

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

Statute Being Implemented: RCW 74.09.510 and 74.09.520.

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

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

Name of Agency Personnel Responsible for Drafting: Wendy Boedigheimer, P.O. Box 45533, Olympia, WA 98504-5533, (360) 725-1306; Implementation and Enforcement: Marlene Black, P.O. Box 45506, Olympia, WA 98504-5506, (360) 725-1577.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The proposed rule does not create more than minor costs for small businesses.

A cost-benefit analysis is not required under RCW 34.05.328. DSHS rules relating to client medical or financial eligibility are exempt from this requirement under RCW 34.05.328 (5)(b)(vii). The proposed rule describes client medical eligibility requirements for covered vision services.

June 29, 2005

Andy Fernando, Manager

Rules and Policies Assistance Unit

3572.1
AMENDATORY SECTION(Amending WSR 05-13-038, filed 6/6/05, effective 7/7/05)

WAC 388-544-0350   Vision care - covered plastic scratch-resistant eyeglass lenses and services.   (1) The medical assistance administration (MAA) covers the following plastic scratch-resistant eyeglass lenses:

(a) Single vision lenses;

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

(c) Flat top trifocals; and

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

(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) 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)) three diopters or greater.

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

(4) MAA covers 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.

[This copy is to be used for proposal only. Statutory Authority: RCW 74.08.090, 74.09.510, 74.09.520 and 42 C.F.R. 440.120 and 440.225. 05-13-038, 388-544-0350, filed 6/6/05, effective 7/7/05. 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.]

Washington State Code Reviser's Office